File: /home/imensosw/www/imenso.co/dev/japfa/register.php
<!doctype html>
<html lang="en-US" >
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="profile" href="http://gmpg.org/xfn/11">
<title>Japfa | Make Good Always</title>
<link rel='stylesheet' href='css/bootstrap.min.css' media='all' />
<link rel='stylesheet' href='css/style.css' media='all' />
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.css" media="all">
<link href="https://fonts.googleapis.com/css2?family=Sen:wght@400;700;800&display=swap" rel="stylesheet">
</head>
<body>
<div class="fw2">
<div class="fw2__left">
<img src="images/wemake.png" class="img-fluid">
</div>
<div class="fw2__right">
<div class="fw2__logo">
<h4 class="mt-5">Register to Japfa <small>(Registered Customers <a href="index.php">Login</a>)</small></h4>
<img src="images/logo.png" width="100">
</div>
<form class="mt-5">
<div class="container-fluid">
<div class="row">
<div class="col-lg-6">
<div class="form-group row">
<div class="col">
<label>First Name</label>
<input type="" class="form-control" name="">
</div>
<div class="col">
<label>Last Name</label>
<input type="" class="form-control" name="">
</div>
</div>
<div class="form-group">
<label>Company Name</label>
<input type="" class="form-control" name="">
</div>
<div class="form-group">
<label>Email Address (Username)</label>
<input type="" class="form-control" name="">
</div>
<div class="form-group">
<label>Phone Number</label>
<input type="" class="form-control" name="">
</div>
<div class="form-group">
<label>GST Number</label>
<input type="" class="form-control" name="">
</div>
<div class="form-group">
<label>PAN Number</label>
<input type="" class="form-control" name="">
</div>
<div class="form-group">
<label>Address</label>
<textarea class="form-control" rows="5"></textarea>
</div>
</div>
<div class="col-lg-6">
<div class="form-group">
<label>KYC Documents</label>
<div class="uploader">
<i class="fa fa-upload fa-2x"></i>
Attach any 3 KYC documents - FSSAI certificate, GST certificate, PAN card
</div>
</div>
<div class="form-group">
<label>Attach your digital signature</label>
<input type="file">
</div>
<div class="form-group">
<label>Terms & Conditions</label>
<p class="small">
Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod
tempor incididunt ut labore et dolore magna aliqua.
</p>
</div>
<div class="form-group">
<div class="form-check">
<input class="form-check-input" type="checkbox">
<label class="form-check-label" for="gridRadios1">
I accept the terms and conditions
</label>
</div>
</div>
<div class="form-group">
<a href="" class="btn btn-primary btn-block mt-5">Register</a>
</div>
</div>
</form>
</div>
</div>
<?php include("footer.php");?>
</body>
</html>