170 lines
6.9 KiB
HTML
170 lines
6.9 KiB
HTML
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<div class="login-bg"></div>
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<bst:widget>
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<!-- Source Country Agent Registration-->
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<bst:widget-header>
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<h3 class="font-widget" th:text="#{Country Agent 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="fsaReg" name="fsaReg">
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<div class="row form-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" id="companyName"
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name="companyName" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company name" />
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</div>
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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 Registration No}" />
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<input type="text" class="form-control"
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id="companyRegistrationNo" name="companyRegistrationNo"
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autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company registration no" />
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</div>
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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 Email}" /> <input
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type="text" class="form-control" id="companyEmail"
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name="companyEmail" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company email" />
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</div>
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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="#{Phone No}" /> <input
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type="text" class="form-control" id="cphoneNo" name="cphoneNo"
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autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Phone no" />
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</div>
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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 Address}" /> <input
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type="text" class="form-control mb-3" id="companyAddress"
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name="companyAddress" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company address" /> <input type="text"
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class="form-control mb-3" id="companyAddress2"
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name="companyAddress2" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company address 1" /> <input type="text"
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class="form-control mb-3" id="companyAddress2"
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name="companyAddress2" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company address 2" />
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</div>
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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="#{Country}" /> <select
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name="countrySelection" id="countrySelection"
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class="form-control">
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<option value="">Select</option>
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<option value="1">Country</option>
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<option value="2">India</option>
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</select>
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</div>
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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="#{Medical Center Licence}" />
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<input type="file" class="form-control" id="medicalCenterLicence"
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name="medicalCenterLicence" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Company address" />
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</div>
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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="text" class="form-control" id="ownerName" name="ownerName"
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autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Owner Name" />
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</div>
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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="#{Phone No}" /> <input
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type="text" class="form-control" id="ownerphoneno"
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name="ownerphoneno" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Phone no" />
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</div>
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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="text" class="form-control" id="ownerEmail"
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name="ownerEmail" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Email" />
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</div>
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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="#{Proof of Identity}" /> <input
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type="file" class="form-control" id="proofOfIdentity"
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name="proofOfIdentity" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();" />
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</div>
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<div class="col-sm-12 col-md-12 col-lg-12 mb-3 mt-3">
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<label><bst:radio name="caRadios" value="C" />
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<th:block th:text="#{Owner and PIC is same}" /></label>
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</div>
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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="#{PIC Name}" /> <input
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type="text" class="form-control" id="picName" name="picName"
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autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="PIC Name" />
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</div>
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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="#{PIC Email}" /> <input
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type="text" class="form-control" id="picEmail" name="picEmail"
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autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="PIC Email" />
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</div>
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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="#{PIC Phone No}" /> <input
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type="text" class="form-control" id="picPhoneNo"
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name="picPhoneNo" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="PIC phone no" />
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</div>
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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="#{PIC Proof of Identity}" />
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<input type="file" class="form-control" id="picproofOfIdentity"
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name="picproofOfIdentity" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Phone no" />
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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="caRadios" 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>
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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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<!-- Country Agent Registration End-->
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</bst:widget>
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