Viewing file:  new_reg.php (8.92 KB) -rw-r--r--
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<?php
include('lock.php');
?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title></title>
<link rel="stylesheet" href="//code.jquery.com/ui/1.11.1/themes/smoothness/jquery-ui.css">
<script src="//code.jquery.com/jquery-1.10.2.js"></script>
<script src="//code.jquery.com/ui/1.11.1/jquery-ui.js"></script>
<link rel="stylesheet" href="/resources/demos/style.css">
<script>
$(function() {
$( "#datepicker" ).datepicker({ dateFormat: 'dd-mm-yy' });
});
</script>
<style type="text/css">
body,td,th {
font-family: Arial, Helvetica, sans-serif;
font-size: 14px;
color: #000;
}
</style>
</head>
<center>
<body>
<form id="form1" name="form1" method="post" action="reg_print.php">
<table width="888" bgcolor="#FFFFFF" height="297" border="0">
<tr>
<td width="882" height="293" align="left" valign="top">
<table width="875" border="0">
<tr>
<td colspan="3" bgcolor="#CCCCCC">Welcome <?php echo $login_session; ?>
</td>
<td> </td>
<td colspan="2" bgcolor="#CCCCCC"><a href="logout.php">Logout</a></td>
<td bgcolor="#CCCCCC"><?php echo "Today is " . date("d/m/y") . "<br>";?></td>
</tr>
<tr>
<td width="158" height="24">Code No</td>
<td width="8">:</td>
<td width="144"><label for="select"></label>
<select name="codeno" type="text" id="codeno" size="00" maxlength="00" required="required">
<option>1222</option>
</select></td>
<td width="27"> </td>
<td width="174">Name of the Nominee</td>
<td width="18">:</td>
<td width="316"><label for="textfield11"></label>
<input name="textfield8" type="text" id="textfield11" size="40" maxlength="40" required="required" tabindex="13"/> <label for="textfield"></label></td>
</tr>
<tr>
<td height="24">Branch Name</td>
<td>:</td>
<td><label for="select"></label>
<select name="branchname" size="0" id="branchname" tabindex="1" type="text" maxlength="00" required="required"">
<option>Pahasa Mau</option>
</select></td>
<td> </td>
<td>Relationship</td>
<td>:</td>
<td><label for="textfield2"></label>
<input type="text" name="textfield9" id="textfield2" required="required" tabindex="14"/></td>
</tr>
<tr>
<td align="left" valign="top">Applicant Name</td>
<td align="left" valign="top">:</td>
<td align="left" valign="top"><input name="applicant" type="text" id="applicant" size="40" maxlength="40" required="required" tabindex="2"/></td>
<td> </td>
<td colspan="3" rowspan="5" align="left" valign="top"><table width="406" height="166" border="0">
<tr>
<td width="206" bgcolor="#CCCCCC">Document Enclosed</td>
<td width="484" bgcolor="#CCCCCC"> </td>
</tr>
<tr>
<td align="right">1</td>
<td><label for="textfield22"></label>
<input name="document1" type="text" id="document1" size="40" tabindex="15"/></td>
</tr>
<tr>
<td align="right">2</td>
<td><label for="textfield23"></label>
<input name="document2" type="text" id="document2" size="40" tabindex="16"/></td>
</tr>
<tr>
<td align="right">3</td>
<td><input name="document3" type="text" id="document3" size="40" tabindex="17" /></td>
</tr>
<tr>
<td align="right">4</td>
<td><label for="textfield24"></label>
<input name="document4" type="text" id="document4" size="40" tabindex="18"/></td>
</tr>
<tr>
<td colspan="2" bgcolor="#CCCCCC">Voter Identiy Card & 3 Copys stamp size photo must be attached</td>
</tr>
</table></td>
</tr>
<tr>
<td>Father's/Husband</td>
<td>:</td>
<td><label for="textfield4"></label>
<input name="f_name" type="text" id="f_name" size="40" maxlength="40" required="required" tabindex="3"/></td>
<td> </td>
</tr>
<tr>
<td>Date of Birth</td>
<td>:</td>
<td><label for="textfield5"></label>
<input type="text" name="dob" id="datepicker" required="required" tabindex="4"/></td>
<td> </td>
</tr>
<tr>
<td>Occupation</td>
<td>:</td>
<td><label for="textfield6"></label>
<input name="occupation" type="text" id="occupation" size="40" required="required" tabindex="5"/></td>
<td> </td>
</tr>
<tr>
<td align="left" valign="top">Permanent Address</td>
<td align="left" valign="top">:</td>
<td align="left" valign="top"><label for="textfield7"></label>
<textarea name="address" cols="30" rows="4" id="address" required="required" tabindex="6"></textarea></td>
<td> </td>
</tr>
<tr>
<td>Phone Number</td>
<td>:</td>
<td><label for="textfield8"></label>
<input name="phone" type="text" id="phone" size="10" maxlength="10" required="required" tabindex="7"/></td>
<td> </td>
<td colspan="3" rowspan="6" align="left" valign="top"><table width="406" height="166" border="0">
<tr>
<td width="206" bgcolor="#CCCCCC">Intoducer Name</td>
<td width="484" bgcolor="#CCCCCC">Code</td>
</tr>
<tr>
<td align="left" valign="top"><label for="textfield18"></label>
<input type="text" name="name" id="name" tabindex="19"/></td>
<td><label for="textfield19"></label>
<input type="text" name="code" id="code" tabindex="19" /></td>
</tr>
<tr>
<td align="left" valign="top"><label for="textfield20"></label>
<input type="text" name="textfield12" id="textfield20" tabindex="20" /></td>
<td><label for="textfield21"></label>
<input type="text" name="textfield17" id="textfield21" /></td>
</tr>
<tr>
<td colspan="2" bgcolor="#CCCCCC">Voter Identiy Card & 3 Copys stamp size photo must be attached</td>
</tr>
</table></td>
</tr>
<tr>
<td>Pan/GIR No</td>
<td>:</td>
<td><label for="textfield10"></label>
<input name="textfield7" type="text" id="textfield10" size="15" required="required" tabindex="8" /></td>
<td> </td>
</tr>
<tr>
<td>Pervious Experience</td>
<td> </td>
<td><label for="textfield14"></label>
<input name="textfield13" type="text" id="textfield14" size="12" tabindex="9"/></td>
<td> </td>
</tr>
<tr>
<td>Nationality</td>
<td> </td>
<td><label for="textfield15"></label>
<input name="textfield14" type="text" id="textfield15" value="Indian" /></td>
<td> </td>
</tr>
<tr>
<td height="31"><label for="textfield16">Religion</label></td>
<td> </td>
<td><input type="text" name="textfield15" id="textfield16" required="required" tabindex="10"/></td>
<td> </td>
</tr>
<tr>
<td>Class of Member</td>
<td> </td>
<td><label for="textfield17"></label>
<input type="text" name="textfield16" id="textfield17" tabindex="11"/></td>
<td> </td>
</tr>
<tr>
<td>Gender</td>
<td> </td>
<td><label for="textfield3"></label>
<label for="textfield9"></label>
<label for="select"></label>
<select name="select" id="select">
<option>MALE</option>
<option>FEMALE</option>
</select></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td><input type="submit" name="button" id="button" value="Submit" tabindex="12" /></td>
<td> </td>
<td> </td>
</tr>
</table>
</td>
</tr>
</table> </form>
</body></center>
</html>
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