<h2 class="page-heading">SPIFF 2022</h2>
<div class="container main">
<form class="spiff-form" data-mage-init='{"validation": {}}' method="post">
<div class="spiff-contents">
<div class="date-icon">
<label for="date">Date</label>
<input type="date" id="date" name="d" placeholder="DD/MM/YYYY" class="required-entry">
</div>
<div class="spiff-maincontents">
<div class="field field-name-firstname required">
<label class="label" for="firstname"><span>First Name</span></label>
<div class="control">
<input type="text" id="firstname"
name="firstname" class="input-text required-entry" minlength="3" pattern="[A-Za-z]" >
</div>
</div>
<div class="field field-name-lastname required">
<label class="label" for="lastname"><span>Last Name</span></label>
<div class="control">
<input type="text" id="lastname"
name="lastname" class="input-text required-entry" pattern="[A-Za-z]" >
</div>
</div>
<div class="field field-name-address required">
<label class="label" for="homeaddress"><span>Home Address</span></label>
<div class="control">
<input type="text" id="homeaddress"
name="address" class="input-text required-entry" pattern="[A-Za-z]" minlength="8">
</div>
</div>
<div class="field field-name-email required">
<label class="label" for="email"><span>Email</span></label>
<div class="control">
<input type="email" id="email"
name="email" class="input-email required-entry">
</div>
</div>
<div class="field field-name-DOB required">
<label class="label" for="month-year"><span>D.O.B. (Day And Month Only)</span></label>
<div class="control">
<input type="text" id="month-dob"
name="date-year" placeholder="MM-YYYY" class="required-entry">
<!-- <input type="text" id="year-dob"-->
<!-- name="date-year" placeholder="YYYY">-->
</div>
</div>
<div class="field field-name-social required">
<label class="label" for="social-security"><span>Social Security</span></label>
<div class="control">
<input type="number" id="social-security"
name="social-security" class="input-number required-entry">
</div>
</div>
<div class="secondary-content">
<div class="secondary-heading">
<h2 class="heading2">
Online SPIFF Informations
</h2>
</div>
<div class="field field-name-routing required">
<label class="label" for="routing-number"><span>ACH Routing Number</span></label>
<div class="control">
<input type="number" id="routing-number"
name="routing-number" class="input-number required-entry">
</div>
</div>
<div class="field field-name-account-number required">
<label class="label" for="account-number"><span>Account Number</span></label>
<div class="control">
<input type="number" id="account-number"
name="account-number" class="input-number required-entry">
</div>
</div>
</div>
</div>
<div class="newspiffblock-content">
<?php
echo $this->getLayout()
->createBlock('Magento\Cms\Block\Block')
->setBlockId('spiff_block')
->toHtml();
?>
</div>
<div class="spiff-othercontent">
<h2 class="contact-heading"> Please return this form with your first eligible order to <b>ar@corpdesign.com</b> </br> or via fax to 954-756-8181 </h2>
</div>
<div class="primary spiffsubmit">
<button type="submit" class="action save primary" title="Save" id="spiffform" >
<span>Submit</span>
</button>
</div>
</div>
</form>
</div>
<script type="text/x-magento-init">
{
".spiff-form": {
"validation": {}
}
}
</script>