146 lines
4.1 KiB
PHP
146 lines
4.1 KiB
PHP
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<div class="container">
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<h3> REGISTER </h3>
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<form class="" method="post" action="<?= base_url()."/register"; ?>" >
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<div class="">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Name</h4></label>
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<input type="text" class="form-control" name="name" id = "name" value="<?= set_value('name') ?>">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Mobile</h4></label>
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<input type="text" class="form-control" name="phone" id="phone" value="<?= set_value('phone') ?>">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Email</h4></label>
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<input type="text" class="form-control" name="email" id="email" value="<?= set_value('email') ?>">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>PAN No</h4></label>
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<input type="text" class="form-control" name="pan" id="pan" value="<?= set_value('pan') ?>">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="col-xs-12">
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<label for="first_name"><h4>Address</h4></label>
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<input type="text" class="form-control" name="address" id="address" placeholder="Flat no , Area" value="<?= set_value('address') ?>">
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</div>
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</div>
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<div class="row">
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<div class="col-md-3">
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<div class="form-group">
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<label for="password2"><h4>Country</h4></label>
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<select name="country" id="country0" class="form-control ">
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<option value="">Select Country</option>
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</select>
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</div>
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</div>
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<div class="col-md-3">
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<div class="form-group">
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<label for="password2"><h4>State</h4></label>
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<select name="state" id="state0" class="form-control ">
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<option value="">Select State</option>
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</select>
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</div>
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</div>
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<div class="col-md-3">
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<div class="form-group">
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<label for="password2"><h4>City</h4></label>
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<select name="city" id="city0" class="form-control ">
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<option value="">Select City</option>
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</select>
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</div>
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</div>
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<div class="col-md-3">
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<div class="form-group">
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<label for="password2"><h4>Pin Code</h4></label>
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<input type="text" class="form-control" name="pin_code" id="pin_code" >
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</select>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Date of Birth</h4></label>
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<input type="text" class="form-control" name="date_of_birth" id="txtDate" placeholder="dd/mm/yyyy" value="<?= set_value('date_of_birth') ?>">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Gender</h4></label>
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<select class="form-control" name="gender" required>
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<option value="">select Gender</option>
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<option value="Male">Male</option>
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<option value="Female">Female</option>
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</select>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Org Name</h4></label>
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<input type="text" class="form-control" name="org_name" id="org_name" value="<?= set_value('org_name') ?>">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>GSTIN</h4></label>
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<input type="text" class="form-control" name="gstin" id="gstin" value="<?= set_value('gstin') ?>">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Password</h4></label>
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<input type="text" class="form-control" name="password" id="password" value="">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="first_name"><h4>Confirm Password</h4></label>
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<input type="text" class="form-control" name="password_confirm" id="password_confirm" value="">
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</div>
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</div>
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</div>
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</br>
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<?php if(isset($validation)): ?>
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<div class="col-12">
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<div class="alert alert-danger" role="aler">
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<?= $validation->listErrors() ?>
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</div>
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</div>
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<?php endif; ?>
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<div class="row">
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<div class="col-12 clo-sm-4">
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<button type="submit" class="btn btn-primary">Register</button>
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</div>
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</div>
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<div class="col-12 clo-sm-8 text-right">
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<a href="<?= base_url()."/"; ?>">Already have an account</a>
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</div>
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</form>
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</div></div>
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