64 lines
2.2 KiB
HTML
64 lines
2.2 KiB
HTML
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<div class="login-bg"></div>
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<bst:widget>
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<!-- Agency Registration -->
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<bst:widget-header>
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<h3 class="font-widget" th:text="#{Agency Registration}" />
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</bst:widget-header>
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<bst:widget-body>
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<div class="row">
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<div class="col-sm-12">
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<form autocomplete="off" id="" name="">
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<div class="row">
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<div class="col-sm-12 col-md-6 col-lg-6 mb-3">
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<label class="required mb-1" th:text="#{Company Name}" /> <input
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type="text" class="form-control form-control-sm" name=""
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value="" />
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</div>
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</div>
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<div class="row">
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<div class="col-sm-12 col-md-6 col-lg-6 mb-3">
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<label class="required mb-1" th:text="#{ROC Number}" /> <input
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type="text" class="form-control form-control-sm" name=""
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value="" />
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</div>
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</div>
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<div class="row">
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<div class="col-sm-12 col-md-6 col-lg-6 mb-3">
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<label class="required mb-1" th:text="#{Mobile Number}" /> <input
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type="text" class="form-control form-control-sm" name=""
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value="" />
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</div>
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</div>
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<div class="row">
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<div class="col-sm-12 col-md-6 col-lg-6 mb-3">
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<label class="required mb-1" th:text="#{Email}" /> <input
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type="email" class="form-control form-control-sm" name=""
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value="" />
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</div>
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</div>
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<div class="row">
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<div class="col-sm-12 col-md-6 col-lg-6 mb-3">
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<label class="required mb-1" th:text="#{Owner Name}" /> <input
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type="email" class="form-control form-control-sm" name=""
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value="" />
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</div>
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</div>
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<div class="col-sm-12 col-md-12 col-lg-12 mt-4">
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<label><bst:checkbox name="" value="C" /> <th:block
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th:text="#{here by declare that the
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information furnished above is true to the best of my knowledge.
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I do hereby declare that above particulars of information and
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facts stated are true, correct and complete to the best of my
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knowledge and belief.}" /></label>
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</div>
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<div class="d-flex pb-4 justify-content-center">
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<button type="submit" class="btn btn-primary">Submit</button>
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<button type="submit" class="btn btn-primary ml-4">Reset</button>
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</div>
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</form>
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</div>
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</div>
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</bst:widget-body>
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</bst:widget>
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