Add New Applicaiton

@if ($errors->any())

{{ $error }}

@endif

First Name:

Please enter your first name

MI:

Please enter your middle name

Last Name:

Please enter your last name

Suffix:

Please enter your suffix

Date of Birth:

Email Address:

Please enter your Email Address

Applicant First Name:

Please enter your first name

Applicant Last Name:

Please enter your last name

Patient is my

Home Phone:

Please enter your home number

Business/work phone:

Please enter Business/work phone Number

Mobile phone:

Please enter your Mobile phone

Home Address

Address Line 1

Please enter your Address Line 1

Address Line 2

Please enter your Address Line 2

City

Please enter your City

State

Please enter your State

Zip Code

Please enter your Zip Code

{{--

--}} {{--Is this your current mailing address?--}} {{--

--}} {{----}} {{----}} {{--same_mail_add == '1' ? 'checked' : '' }} name="same_mail_add">--}} {{----}} {{----}} {{----}} {{--

--}} {{--

same_mail_add == '1' ? 'style=display:none' : '' }}>--}} {{--

Mailing Address

--}} {{--

--}} {{--Address Line 1--}} {{--

--}} {{--

--}} {{----}} {{--

--}} {{--Please enter your Address Line 1--}} {{--

--}} {{--Address Line 2--}} {{--

--}} {{----}} {{--Please enter your Address Line 2--}} {{--

--}} {{--

--}} {{--City--}} {{--

--}} {{--

--}} {{----}} {{--

--}} {{--Please enter your City--}} {{--

--}} {{--State--}} {{--

--}} {{----}} {{--Please enter your State--}} {{--

--}} {{--Zip Code--}} {{--

--}} {{----}} {{--Please enter your Zip Code--}} {{--

--}} {{--

--}}

Housing status

house_status=='Own')? "checked" : "" }} required> Own house_status=='Rent')? "checked" : "" }} required> Rent house_status=='Other')? "checked" : "" }} required> Other

Please choose one

Amount Requested:

Please enter required amount

Social Security:

Please enter your Social Security

Monthly net income

Please enter your Monthly net income from all sources

{!! csrf_field() !!}

{{--

--}}