ChemShopProject/registration.html at main · simsid124/ChemShopProject · GitHub

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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">

<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<!------ Include the above in your HEAD tag ---------->
<style>
    /* body { */
        li:hover {
    background-color: #C8C8C8 ;
}
 .blue {
    color: green;
}
      form {
          padding-left: 20px;
          padding-right: 10px;
      }
</style>
</head>
<body>
<nav class="navbar navbar-default navbar-fixed-top">
  <div class="container-fluid">
    <div class="navbar-header">
 <ul class="nav navbar-nav navbar-right">
        <li><a style="color:0099FF" href="index.html"><span class="glyphicon glyphicon-log-out"></span>Logout</a></li>
      </ul>
      </div>
    </div>
</nav>
      <div class="container" style="margin-top:50px;">
        <form class="form-horizontal" method="post" action="">
          <fieldset>

          <div id="edit_farmer" style="display:none"></div>
          <div class="row">
            <div class="col-md-2 panel panel-heading">Contact Information</div>
            <div class="col-md-4 panel panel-heading" style="display:none; color:red" id="contact_error"></div>
          </div>
          <div class="row form-group">
          <label class="col-md-1 control-label" for="Username">Username</label>
            <div class="col-md-3">
			<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-user"></i>
			</span>
              <input  placeholder="" class="form-control input-md" type="text" required="required">
            </div></div>

            <label class="col-md-1 control-label" for="middle_name">Password</label>
            <div class="col-md-3">
			<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-pencil"></i>
			</span>
              <input  placeholder="" class="form-control input-md" type="password" required="required">
            </div>
		</div>
            <label class="col-md-1 control-label" for="last_name">Confirm password</label>
            <div class="col-md-3">
			<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-pencil"></i>
			</span>
              <input placeholder="" class="form-control input-md" type="password" required="required">
            </div>
	</div>
          </div>

          <div class="row form-group">
            <label class="col-md-1 control-label" for="first_name">First Name</label>
            <div class="col-md-3">
			<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-user"></i>
			</span>
              <input  placeholder="" class="form-control input-md" type="text">
            </div></div>

            <label class="col-md-1 control-label" for="last_name">Last Name</label>
            <div class="col-md-3">
			<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-user"></i>
			</span>
              <input placeholder="" class="form-control input-md" type="text">
            </div>
	</div>
          </div>
          <div class="row form-group">
            <label class="col-md-1 control-label" for="mobile">Contact No.</label>
            <div class="col-md-3">
    <div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-phone"></i>
			</span>
              <input id="mobile" maxlength="10" name="mobile" placeholder="xxxxxxxxxxxx" class="form-control input-md ac_mobile" type="number" value={{mobile}} >

            </div>
	</div>

          <div class="row form-group">
            <label class="col-md-2 control-label" for="farmer_type">Position</label>
            <div class="col-md-4">
              <label class="radio-inline"><input type="radio" name="Position" value="Farmer" checked>Employee</label>
              <label class="radio-inline"><input type="radio" name="Position" value="Politician">Student</label>
              <label class="radio-inline"><input type="radio" name="Position" value="Retailer">Professor</label>
              <label class="radio-inline"><input type="radio" name="Position" value="Supplier">Teacher</label>
            </div>
          </div>
          <div class="row form-group">
            <label class="col-md-2 control-label" for="Organization Name">Organization Name</label>
              <div class="col-md-4">
              <div class="input-group">
              <span class="input-group-addon">
              <i class="glyphicon glyphicon-pencil"></i>
              </span>
                <input  placeholder="" class="form-control input-md" type="text">
              </div></div>

              <label class="col-md-2 control-label" for="Email Address">Email Address</label>
              <div class="col-md-4">
              <div class="input-group">
              <span class="input-group-addon">
              <i class="glyphicon glyphicon-pencil"></i>
              </span>
                <input type="email" action="/action_page.php" placeholder="" class="form-control input-md">
              </div></div>
          </div>
          <div class="row">
            <div class="col-md-2 panel panel-heading">Address Information</div>
            <div class="col-md-4 panel panel-heading" style="display:none; color:red" id="address_error"></div>
          </div>

          <div class="row form-group">
            <label class="col-md-1 control-label" for="state">District</label>
            <div class="col-md-2">
		<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-list"></i>
			</span>

              <input  placeholder="" class="form-control input-md ac_state" required="" type="text">
            </div></div>

            <label class="col-md-1 control-label" for="district">State</label>
            <div class="col-md-2">
		<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-list"></i>
			</span>

              <input  placeholder="" class="form-control input-md ac_district" required="" type="text">
            </div>
		</div>
        <label class="col-md-1 control-label" for="district">Country</label>
        <div class="col-md-2">
    <div class="input-group">
        <span class="input-group-addon">
        <i class="glyphicon glyphicon-list"></i>
        </span>

          <input  placeholder="" class="form-control input-md ac_district" required="" type="text">
        </div>
    </div>
          </div>

          <div class="row form-group">
            <label class="col-md-1 control-label" for="pin_code">Pin Code</label>
            <div class="col-md-2">
              <input id="pin_code" name="pin_code" placeholder=""  class="form-control input-md" required="" type="text">
            </div>

            <label class="col-md-1 control-label" for="address">Address</label>
            <div class="col-md-5">
		<div class="input-group">
			<span class="input-group-addon">
			<i class="glyphicon glyphicon-pencil"></i>
			</span>
              <textarea class="form-control" placeholder="Addess Details..."></textarea>
            </div>
	</div>
          </div>
          <div class="form-group row">
            <label class="form-check-label"><input type="checkbox" required="required"> I accept the <a href="#">Terms &amp; Conditions</a></label>
        <br><br>
              <input type="submit" id="save" name="save" class="btn btn-large btn-success"></input>
          </div>
            </fieldset>
        </form>
      </div>
</body>
</html>