140 lines
9.9 KiB
PHP
140 lines
9.9 KiB
PHP
<div class="row">
|
|
<div class="col-lg-12">
|
|
<div class="card">
|
|
<div class="card-body">
|
|
<h4 class="header-title"><?= $page_name; ?></h4>
|
|
<p class="sub-header"> </p>
|
|
<form>
|
|
<div class="form-group">
|
|
<div class="form-row">
|
|
<div class="form-group col-md-6">
|
|
<label for="inputName" class="col-form-label">Name<span class="text-danger">*</span></label>
|
|
<input type="text" class="form-control" id="inputName" placeholder="Name" required />
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<label for="inputEmail" class="col-form-label">Email<span class="text-danger">*</span></label>
|
|
<input type="email" class="form-control" id="inputEmail" placeholder="Email" required />
|
|
</div>
|
|
</div>
|
|
<div class="form-row">
|
|
<div class="form-group col-md-6">
|
|
<label for="inputDOB" class="col-form-label">Date Of Birth<span class="text-danger">*</span></label>
|
|
<input type="date" class="form-control" id="inputDOB" placeholder="DD/MM/YYYY" required data-toggle="input-mask" data-mask-format="00/00/0000" />
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<label for="inputMobile" class="col-form-label">Mobile Number<span class="text-danger">*</span></label>
|
|
<input type="text" class="form-control" id="inputMobile" placeholder="Enter only numbers" required data-parsley-type="number" />
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<label for="inputAddress" class="col-form-label">Address<span class="text-danger">*</span></label>
|
|
<input type="text" class="form-control" id="inputAddress" placeholder="1234 Main St" required />
|
|
</div>
|
|
<div class="form-group">
|
|
<label for="inputAddress2" class="col-form-label">Address 2</label>
|
|
<input type="text" class="form-control" id="inputAddress2" placeholder="Apartment, studio, or floor" />
|
|
</div>
|
|
<div class="form-row">
|
|
<div class="form-group col-md-6">
|
|
<label for="inputCity" class="col-form-label">City<span class="text-danger">*</span></label>
|
|
<input type="text" class="form-control" id="inputCity" placeholder="city" required />
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<label for="inputState" class="col-form-label">State<span class="text-danger">*</span></label>
|
|
<select id="inputState" class="form-control" required />
|
|
<option>Choose</option>
|
|
<option>Option 1</option>
|
|
<option>Option 2</option>
|
|
<option>Option 3</option>
|
|
|
|
</select>
|
|
</div>
|
|
<div class="form-group col-md-2">
|
|
<label for="inputZip" class="col-form-label">Zip<span class="text-danger">*</span></label>
|
|
<input type="text" class="form-control" id="inputZip" placeholder="Zip" required />
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group text-right m-b-0 checkbox checkbox-purple">
|
|
<input type="checkbox" id="inputCheckbox" class="form-control" checked="true">
|
|
<label for="inputCheckbox">Is Active</label>
|
|
</div>
|
|
<br>
|
|
|
|
|
|
<div class="form-group text-right m-b-0">
|
|
<button class="btn btn-primary waves-effect waves-light mr-1" type="submit">
|
|
Submit
|
|
</button>
|
|
<button type="reset" class="btn btn-secondary waves-effect">
|
|
Cancel
|
|
</button>
|
|
</div>
|
|
</form>
|
|
|
|
<!-- <form class="needs-validation" novalidate>
|
|
<div class="form-group mb-3">
|
|
<label for="userName">User Name<span class="text-danger">*</span></label>
|
|
<input type="text" class="form-control" id="validationCustom01" placeholder="First name" required>
|
|
<div class="<?php if ("valid-feedback") {
|
|
echo "valid-feedback";
|
|
} ?>" >Looks good!</div>
|
|
<div class="<?php if ("invalid-feedback") {
|
|
echo "invalid-feedback";
|
|
} ?>" >Please provide a valid User name.</div>
|
|
</div>
|
|
<div class="form-group mb-3">
|
|
<label for="address">Address<span class="text-danger">*</span></label>
|
|
<div><textarea required class="form-control"></textarea></div>
|
|
<div class="<?php if ("valid-feedback") {
|
|
echo "valid-feedback";
|
|
} ?>" >Looks good!</div>
|
|
<div class="<?php if ("invalid-feedback") {
|
|
echo "invalid-feedback";
|
|
} ?>" >Please provide a valid Adress.</div>
|
|
</div>
|
|
<div class="form-group mb-1">
|
|
<label for="validationCustom03">City</label>
|
|
<input type="text" class="form-control" id="validationCustom03" placeholder="City" required>
|
|
<div class="<?php if ("valid-feedback") {
|
|
echo "valid-feedback";
|
|
} ?>" >Looks good!</div>
|
|
<div class="<?php if ("invalid-feedback") {
|
|
echo "invalid-feedback";
|
|
} ?>" >Please provide a valid city.</div>
|
|
</div>
|
|
<div class="form-group mb-1">
|
|
<label for="validationCustom04">State</label>
|
|
<input type="text" class="form-control" id="validationCustom04" placeholder="State" required>
|
|
<div class="<?php if ("valid-feedback") {
|
|
echo "valid-feedback";
|
|
} ?>" >Looks good!</div>
|
|
<div class="<?php if ("invalid-feedback") {
|
|
echo "invalid-feedback";
|
|
} ?>" >Please provide a valid state.</div>
|
|
</div>
|
|
<div class="form-group mb-1">
|
|
<label for="validationCustom05">Zip</label>
|
|
<input type="text" class="form-control" id="validationCustom05" placeholder="Zip" required>
|
|
<div class="<?php if ("valid-feedback") {
|
|
echo "valid-feedback";
|
|
} ?>" >Looks good!</div>
|
|
<div class="<?php if ("invalid-feedback") {
|
|
echo "invalid-feedback";
|
|
} ?>" >Please provide a valid Zip.</div>
|
|
</div>
|
|
<div class="form-group mb-3">
|
|
|
|
</div>
|
|
<div class="form-group mb-3">
|
|
<label>E-Mail</label>
|
|
<input type="email" class="form-control" required parsley-type="email" placeholder="Enter a valid e-mail"/>
|
|
</div>
|
|
<button class="btn btn-primary" type="submit">Submit form</button>
|
|
</form> -->
|
|
|
|
</div> <!-- end card-body-->
|
|
</div> <!-- end card-->
|
|
</div> <!-- end col-->
|
|
</div>
|
|
<!-- end row -->
|