"dfgdfgdfd"
Bootstrap 4.1.1 Snippet by ravic9089

Post to Facebook Tweet this

<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/js/bootstrap.min.js"></script> <script src="//cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script> <!------ Include the above in your HEAD tag ----------> <!DOCTYPE html> <html lang="en"> <head> <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1"> <link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.4.0/css/bootstrap.min.css"> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.4.1/jquery.min.js"></script> <script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.4.0/js/bootstrap.min.js"></script> <link rel="stylesheet" href="https://code.jquery.com/ui/1.12.1/themes/base/jquery-ui.css"> <script src="https://code.jquery.com/jquery-1.12.4.js"></script> <script src="https://code.jquery.com/ui/1.12.1/jquery-ui.js"></script> </head> <body> <style> .form1-sec{ margin-bottom:30px; } .declaine-page { margin-top:0%; height: 100%; padding: 10px; background: #e8edf1d9; border-radius: 11px; box-shadow: 1px 1px #eee; } #colorback { width: 100%; background: #044d8e; padding: 9px 0px; margin-bottom: 19px; color: aliceblue; font-size: 19px; } .headingmr{ color:#0d83ec; } .starcolr{ color:red; } label.control-label.col-sm-4 { text-align: left; } @media (max-width: 768px){ .declaine-page { margin-top: 1%; height: 100%; width: 356px; background: #e8edf1d9; border-radius: 11px; box-shadow: 1px 1px #eee; } } </style> <form id="reg_form" action="http://technosys.org.in/portal/admin/addStudent" class="form-horizontal" method="post"> <section id="section_1" class="form1-sec"> <div class="container"> <div class="row"> <h3 class="text-center headingmr">dfgfgf</h3> </div> <div class="row"> <div class="declaine-page"> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Applicant's Basic Information</h3> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Salutation">Salutation<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select class="form-control" name="salutation" id="Salutation"> <option value="">Please Select </option> <option>Mr.</option> <option>Mrs.</option> <option>Miss</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="FirstName">First Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="FirstName" placeholder="Enter First Name" name="FirstName"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="MiddleName">Middle Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="MiddleName" placeholder="Enter Middle Name" name="MiddleName"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="LastName">Last Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="LastName" placeholder="Enter Last Name" name="LastName"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="DateofBirth">Date of Birth<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="date" class="form-control" id="DateofBirth" placeholder="Enter Merchant Login Id" name="DateofBirth"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Age">Age<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="Age" placeholder="Enter Age" name="Age"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="SelectGender">Select Gender<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select name="gender" class="form-control" id="SelectGender"> <option value="">Please Select </option> <option>Male</option> <option>Female</option> <option>Other</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="DateofApplication">Date of Application<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="date" class="form-control" id="DateofApplication" placeholder="Enter Date of Application" name="DateofApplication"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Mobileno">Mobile No:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="Mobileno" placeholder="Enter Mobile No" name="Mobileno"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Email">Email:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="Email" placeholder="Enter Email" name="Email"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="AadhaarNumber">Aadhaar Card Number:</label> <div class="col-sm-8"> <input type="text" class="form-control" id="AadhaarNumber" placeholder="Enter Aadhaar Number" name="AadhaarNumber"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="BPL">BPL:</label> <div class="col-sm-8"> <select class="form-control" name="bpl" id="BPL"> <option value="">Please Select </option> <option>Male</option> <option>Female</option> <option>Other</option> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Caste">Caste<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select class="form-control" name="caste" id="Caste"> <option readonly value="">Please Select </option> <option>OBC</option> <option>SC</option> <option>ST</option> <option>General</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Religion">Religion<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select name="religion" class="form-control" id="Religion"> <option value="">Please Select </option> <option>Hindu</option> <option>Muslim</option> <option>Other</option> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="MaritalStatus">Marital Status<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select class="form-control" name="marital_status" id="MaritalStatus"> <option value="">Please Select </option> <option>Mrried</option> <option>Unmarried</option> </select> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Present Address</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Country">Country<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select name="country"class="form-control" id="Country"> <option value="">Please Select </option> <option>India</option> <option>America</option> <option>Indonisia</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="State">State<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select name="state" class="form-control" id="State"> <option value="">Please Select </option> <option>Andhra Pradesh</option> <option>Arunachal Pradesh</option> <option>Assam</option> <option>Bihar</option> <option>Chhattisgarh</option> <option>Goa</option> <option>Gujarat</option> <option>Haryana</option> <option>Himachal Pradesh</option> <option>Jammu & Kashmir</option> <option>Jharkhand</option> <option>Karnataka</option> <option>Kerala</option> <option>Madhya Pradesh</option> <option>Maharashtra</option> <option>Manipur</option> <option>Meghalaya</option> <option>Mizoram</option> <option>Nagaland</option> <option>Odisha</option> <option>Punjab</option> <option>Rajasthan</option> <option>Sikkim</option> <option>Tamil Nadu</option> <option>Tripura</option> <option>Uttarakhand</option> <option>Uttar Pradesh</option> <option>West Bengal</option> <!-- <option>Westbengal</option> <option>Uttarpradesh</option> <option>Madhyapradesh</option>--> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="District">District<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" name="district" class="form-control" id="District" /> <!--<select name="district" class="form-control" id="District"> <option value="">Please Select </option> <option>Howrah</option> <option>Howrah</option> <option>Howrah</option> </select>--> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Sub-division">Sub-division<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" name="sub_division" class="form-control" id="Sub-division" /> <!-- <select name="sub_division" class="form-control" id="Sub-division"> <option value="">Please Select </option> <option>sub_division 1</option> <option>sub_division 2</option> <option>sub_division 3</option> </select>--> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Rural/Urban">Rural/Urban<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select class="form-control" name="rul_urb" id="Rural/Urban"> <option value="">Please Select </option> <option>Rural</option> <option>Urban</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Block/Municipality/Corporation">Block/Municipality/Corporation<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input type="text" name="block_municipality" class="form-control" id="Block_Municipality_Corporation" /> <!--<select name="block_municipality" class="form-control" id="Block_Municipality_Corporation"> <option value="">Please Select </option> <option>Block</option> <option>Municipality</option> <option>Corporation</option> </select>--> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Village/Ward">Village/Ward:</label> <div class="col-sm-8"> <select name="village_ward" class="form-control" id="Village_Ward"> <option value="">Please Select </option> <option>Village</option> <option>Ward</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="PoliceStation">Police Station:</label> <div class="col-sm-8"> <input type="text" name="police_station" class="form-control" id="PoliceStation" /> <!--<select name="police_station" class="form-control" id="PoliceStation"> <option value="">Please Select </option> <option>Liuah</option> <option>Howrah</option> <option>Kolkata</option> </select>--> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="postoffice">Post Office<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input name="post_office" type="text" class="form-control" id="postoffice" placeholder="Enter Post Office" name="postoffice"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="address1">Address Line 1<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <textarea name="address_one" type="text" class="form-control" id="address1" placeholder="Enter Address Line 1" name="address1"></textarea> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="address2">Address Line 2:</label> <div class="col-sm-8"> <textarea name="address_two" type="text" class="form-control" id="address2" placeholder="Enter Address Line 2" name="address2"></textarea> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="pincode">Pin Code<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input name="pin_code" type="text" class="form-control" id="pincode" placeholder="Enter Pin Code" name="pincode"> </div> </div> </div> </div> </div> <div class="row"> <center><button onclick="resetForm()" class="btn btn-primary ">Reset</button>      <span><button type="button" class="btn btn-primary ">Cancel</button>      <input type="button" class="btn btn-primary " id="next_part" value="Save & Next"> </input></span></center> </div> </div> </div> </div> </section> <section id="section_2"class="form1-sec"> <div class="container"> <div class="row"> <h3 class="text-center headingmr">Application For Building and other Construction Worker's Beneficiary Registration Process</h3> </div> <div class="row"> <div class="declaine-page"> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Parent or Husband details</h3> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Parent or Husband">Parent or Husband <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="parent_husband" class="form-control" id="Parent or Husband"> <option value="">Please Select </option> <option>Parent</option> <option>Husband</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Salutation">Salutation<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="parent_husband_salutation" class="form-control" id="Salutation"> <option value="">Please Select </option> <option>Mr.</option> <option>Mrs.</option> <option>Miss</option> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="FirstName">First Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required type="text" class="form-control" id="FirstName" placeholder="Enter First Name" name="parent_first_name"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="MiddleName">Middle Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required type="text" class="form-control" id="MiddleName" placeholder="Enter Middle Name" name="parent_middle_name"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="LastName">Last Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required type="text" class="form-control" id="LastName" placeholder="Enter Last Name" name="parent_last_name"> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Permanent Address of Applicant</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Country">Country<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="parmanent_country" class="form-control" id="Country"> <option value="">Please Select </option> <option>India</option> <option>America</option> <option>Indonisia</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="State">State<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="parmanent_state" class="form-control" id="State"> <option value="">Please Select </option> <option>Andhra Pradesh</option> <option>Arunachal Pradesh</option> <option>Assam</option> <option>Bihar</option> <option>Chhattisgarh</option> <option>Goa</option> <option>Gujarat</option> <option>Haryana</option> <option>Himachal Pradesh</option> <option>Jammu & Kashmir</option> <option>Jharkhand</option> <option>Karnataka</option> <option>Kerala</option> <option>Madhya Pradesh</option> <option>Maharashtra</option> <option>Manipur</option> <option>Meghalaya</option> <option>Mizoram</option> <option>Nagaland</option> <option>Odisha</option> <option>Punjab</option> <option>Rajasthan</option> <option>Sikkim</option> <option>Tamil Nadu</option> <option>Tripura</option> <option>Uttarakhand</option> <option>Uttar Pradesh</option> <option>West Bengal</option> <!-- <option>Westbengal</option> <option>Uttarpradesh</option> <option>Madhyapradesh</option>--> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="District">District<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required type="text" name="parmanent_district" class="form-control" id="District" /> <!--<select required class="form-control" name="parmanent_district" id="District"> <option value="">Please Select </option> <option>Howrah</option> <option>Howrah</option> <option>Howrah</option> </select>--> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Sub-division">Sub-division<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required type="text" name="parmanent_subdivision" class="form-control" id="Sub-division" /> <!-- <select required name="parmanent_subdivision" class="form-control" id="Sub-division"> <option value="">Please Select </option> <option>sub_division 1</option> <option>sub_division 2</option> <option>sub_division 3</option> </select>--> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Rural/Urban">Rural/Urban<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="parmanent_rular_urban" class="form-control" id="Rural/Urban"> <option value="">Please Select </option> <option>Rural</option> <option>Urban</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Block/Municipality/Corporation">Block/Municipality/Corporation<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required type="text" name="parmanent_block" class="form-control" id="Block/Municipality/Corporation" /> <!--<select required name="parmanent_block" class="form-control" id="Block/Municipality/Corporation"> <option value="">Please Select </option> <option>Block</option> <option>Municipality</option> <option>Corporation</option> </select>--> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Village/Ward">Village/Ward:</label> <div class="col-sm-8"> <select required name="parmanent_village_ward" class="form-control" id="Village/Ward"> <option value="">Please Select </option> <option>Village</option> <option>Ward</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="PoliceStation">Police Station:</label> <div class="col-sm-8"> <input required type="text" name="parmanent_police_station" class="form-control" id="PoliceStation" /> <!--<select required name="parmanent_police_station" class="form-control" id="PoliceStation"> <option value="">Please Select </option> <option>Liluah</option> <option>Howrah</option> <option>Kolkata</option> </select>--> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="postoffice">Post Office<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="parmanent_post_office" type="text" class="form-control" id="pincode" placeholder="Enter Post Office" name="postoffice"> </div> </div> </div> </div> <div class="col-md-12"> <!-- <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Block/Municipality/Corporation">Block/Municipality/Corporation<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="parmanent_municipality" class="form-control" id="Block/Municipality/Corporation"> <option value="">Please Select </option> <option>Block</option> <option>Municipality</option> <option>Corporation</option> </select> </div> </div> </div>--> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="address1">Address Line 1<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <textarea required name="parmanent_address1" type="text" class="form-control" id="address1" placeholder="Enter Address Line 1" name="address1"></textarea> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="address2">Address Line 2:</label> <div class="col-sm-8"> <textarea required name="parmanent_address2" type="text" class="form-control" id="address2" placeholder="Enter Address Line 2" name="address2"></textarea> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="pincode">Pin Code<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="parmanent_pincode" type="text" class="form-control" id="pincode" placeholder="Enter Pin Code" name="pincode"> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Employment Details of Last 12 Months</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Country">Name of the Employer ::</label> <div class="col-sm-8"> <select required name="emp_name" class="form-control" id="Country"> <option value="">Please Select </option> <option>1</option> <option>2</option> <option>3</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="State">Address of the Employer:</label> <div class="col-sm-8"> <select required name="emp_address" class="form-control" id="State"> <option value="">Please Select </option> <option>1</option> <option>2</option> <option>3</option> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Workplace Details and Address">Workplace Details and Address:</label> <div class="col-sm-8"> <input required name="emp_workplace" type="text" class="form-control" id="Workplace Details and Address" placeholder="Enter Workplace Details and Address" name="Workplace Details and Address"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Registration No. of the Institute">Registration No. of the Institute:</label> <div class="col-sm-8"> <input required name="emp_registration_no_of_institute" type="text" class="form-control" id="Registration No. of the Institute" placeholder="Enter Registration No. of the Institute" name="Registration No. of the Institute"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Nature of Job">Nature of Job <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="emp_job_nature" type="text" class="form-control" id="Nature of Job" placeholder="Enter Nature of Job" name="Nature of Job"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Employment Start Date">Employment Start Date<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="emp_start_date" type="date" class="form-control" id="Employment Start Date" placeholder="Enter Employment Start Date" name="Employment Start Date"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Employment End Date">Employment End Date<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="emp_end_date" type="date" class="form-control" id="Employment End Date" placeholder="Enter Employment End Date" name="Employment End Date"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="No. of Actual Working Days">No. of Actual Working Days:</label> <div class="col-sm-8"> <input required name="emp_actual_working_days" type="date" class="form-control" id="No. of Actual Working Days" placeholder="Enter No. of Actual Working Days" name="No. of Actual Working Days"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Remarks">Remarks :</label> <div class="col-sm-8"> <input required name="emp_remarks" type="text" class="form-control" id="Remarks" placeholder="Enter Remarks" name="Remarks"> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Bank Details</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Bank Name">Bank Name :</label> <div class="col-sm-8"> <input required name="bank_name" type="text" class="form-control" id="Bank Name" placeholder="Enter Bank Name" name="Bank Name"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Branch Details ">Branch Details :</label> <div class="col-sm-8"> <input required name="bank_branch" type="text" class="form-control" id="Branch Details" placeholder="Enter Branch Details " name="Branch Details "> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="IFSC Code">IFSC Code :</label> <div class="col-sm-8"> <input required name="bank_ifsc_code" type="text" class="form-control" id="IFSC Code" placeholder="Enter IFSC Code" name="IFSC Code"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Acount No">Acount No :</label> <div class="col-sm-8"> <input required name="bank_acc_no" type="text" class="form-control" id="Acount No" placeholder="Enter Acount No" name="Acount No"> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Dependent Family Members Details</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Name">Name<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="family_member_name" type="text" class="form-control" id="Name" placeholder="Enter Name" name="Name"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Age of Dependent Member">Age of Dependent Member<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="family_member_age" type="text" class="form-control" id="Age of Dependent Member" placeholder="Enter Age of Dependent Member" name="Age of Dependent Member"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Relation with the Dependent Member">Relation with the Dependent Member<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="family_member_relation" class="form-control" id="Relation with the Dependent Member"> <option value="">Please Select </option> <option>1</option> <option>2</option> <option>3</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Gender of Dependent Member">Gender of Dependent Member<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="family_member_gender" class="form-control" id="Gender of Dependent Member"> <option value="">Please Select </option> <option>Male</option> <option>Female</option> <option>Other</option> </select> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Nominee Details</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Name of Nominee">Name of Nominee<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="nominee_name" type="text" class="form-control" id="Name of Nominee" placeholder="Enter Name of Nominee" name="Name of Nominee"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Address of Nominee">Address of Nominee<span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="nominee_address" type="text" class="form-control" id="Address of Nominee" placeholder="Enter Address of Nominee" name="Address of Nominee"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Age of Nominee">Age of Nominee <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="nominee_age" type="text" class="form-control" id="Age of Nominee" placeholder="Enter Age of Nominee" name="Age of Nominee"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Relation with Nominee">Relation with Nominee <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="nominee_relation" class="form-control" id="Relation with Nominee "> <option value="">Please Select </option> <option>1</option> <option>2</option> <option>3</option> </select> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Gender of Nominee">Gender of Nominee <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="nominee_gender" class="form-control" id="Gender of Nominee"> <option value="">Please Select </option> <option>Male</option> <option>Female</option> <option>Other</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Share of Nominee ">Share of Nominee <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <input required name="nominee_share" type="text" class="form-control" id="Share of Nominee " placeholder="Enter Share of Nominee " name="Share of Nominee "> </div> </div> </div> </div> </div> <div class="row"> <div class="col-md-12"> <h3 class="text-center" id="colorback">Other Details</h3> </div> </div> <div class="row"> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="PF No">PF No.:</label> <div class="col-sm-8"> <input required name="pf_no" type="text" class="form-control" id="PF No" placeholder="Enter PF No" name="PF No"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="ESI No">ESI No.:</label> <div class="col-sm-8"> <input required name="esi_no" type="text" class="form-control" id="ESI No" placeholder="Enter ESI No" name="ESI No"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Particulars of documents regarding submission of Registration fees">Particulars of documents regarding submission of Registration fees:</label> <div class="col-sm-8"> <input required name="document_registration_fee" type="text" class="form-control" id="Particulars of documents regarding submission of Registration fees" placeholder="Enter Particulars of documents regarding submission of Registration fees " name="Particulars of documents regarding submission of Registration fees"> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Rate of Subscription">Rate of Subscription:</label> <div class="col-sm-8"> <input required name="subscription_rate" type="text" class="form-control" id="Rate of Subscription" placeholder="Enter Rate of Subscription" name="Rate of Subscription"> </div> </div> </div> </div> <div class="col-md-12"> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Status of Construction Worker ">Status of Construction Worker <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select name="worker_status" class="form-control" id="Status of Construction Worker "> <option value="">Please Select </option> <option>1</option> <option>2</option> <option>3</option> </select> </div> </div> </div> <div class="col-md-6"> <div class="form-group"> <label class="control-label col-sm-4" class="text-left" for="Certificate of identification attached">Certificate of identification attached <span class="starcolr">*</span>:</label> <div class="col-sm-8"> <select required name="certification_identification" class="form-control" id="Certificate of identification attached"> <option value="">Please Select </option> <option>1</option> <option>2</option> <option>3</option> </select> </div> </div> </div> </div> </div> <div class="row"> <center> <div class="form-group form-check"> <label class="form-check-label"> <input required name="agree" class="form-check-input" type="checkbox"> I hereby declare that the above information is true to the best of my knowledge and belief I Accept </label> </div></center> <br> </div> <div class="row"> <center><button type="button" class="btn btn-primary ">Reset</button>      <span><button type="button" class="btn btn-primary ">Cancel</button>      <input type="submit" class="btn btn-primary " id="sub" value="Submit" /></span></center> </div> </div> </div> <!-- testing eend --> </div> </section> </form> <div id="dialog" style="display:none;" title="Basic dialog"> <p>Some Fields are Empty...</p> </div> </body> </html> <script> function resetForm() { document.getElementById("reg_form").reset(); } $(document).ready(function(){ $('#section_2').hide(); }); $('#next_part').click(function(){ var salution=$('#Salutation').val(); var FirstName=$('#FirstName').val(); var MiddleName=$('#MiddleName').val(); var LastName=$('#LastName').val(); var DateofBirth=$('#DateofBirth').val(); var Age=$('#Age').val(); var DateofApplication=$('#DateofApplication').val(); var Mobileno=$('#Mobileno').val(); var Email=$('#Email').val(); var AadhaarNumber=$('#AadhaarNumber').val(); var BPL=$('#BPL').val(); var Caste=$('#Caste').val(); var Religion=$('#Religion').val(); var MaritalStatus=$('#MaritalStatus').val(); var Country=$('#Country').val(); var State=$('#State').val(); var District=$('#District').val(); var Sub_division=$('#Sub-division').val(); var Rural_Urban=$('#Rural_Urban').val(); var Block_Municipality_Corporation=$('#Block_Municipality_Corporation').val(); var Village_Ward=$('#Village_Ward').val(); var PoliceStation=$('#PoliceStation').val(); var postoffice=$('#postoffice').val(); var address1=$('#address1').val(); var address2=$('#address2').val(); var pincode=$('#pincode').val(); if(salution=='' || FirstName=='' || MiddleName=='' || LastName=='' || DateofBirth=='' || Age=='' || DateofApplication=='' || Mobileno=='' || Email=='' || AadhaarNumber=='' || BPL=='' || Caste=='' || Religion=='' || MaritalStatus=='' || Country=='' || State=='' || District=='' || Sub_division=='' || Rural_Urban=='' || Block_Municipality_Corporation=='' || Village_Ward=='' || PoliceStation=='' || postoffice=='' || address1=='' || address2=='' || pincode=='' ){ // alert("some fields are empty"); $( "#dialog" ).show(); $( "#dialog" ).dialog(); }else{ var result=confirm("Do you want to save it ?"); if(result){ $('#section_1').fadeOut('slow'); $("html, body").animate({ scrollTop: 0 }, "slow"); $('#section_2').fadeIn("fast"); } } }); $('body').on('click','#sub',function(){ // $('#section_1').show(); }); </script>

Related: See More

Material Dashboard Pro React

Questions / Comments: