324 lines
12 KiB
HTML
324 lines
12 KiB
HTML
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<div class="login-bg"></div>
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<bst:widget>
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<!-- Medical Center Registration-->
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<bst:widget-header>
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<h3 class="font-widget" th:text="#{Medical Center 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="fmcReg" name="fmcReg">
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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="#{Medical Center Name}" />
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<input type="text" class="form-control" id="medicalCenterName"
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name="medicalCenterName" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Medical Center 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="#{Employer Email}" /> <input
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type="text" class="form-control" id="employerEmail"
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name="employerEmail" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Employer 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="#{Medical Center Address}" />
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<input type="text" class="form-control mb-3"
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id="medicalCenterAddress" name="medicalCenterAddress"
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autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Address1" /> <input type="text"
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class="form-control mb-3" id="medicalCenterAddress2"
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name="medicalCenterAddress2" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Address2" /> <input type="text"
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class="form-control mb-3" id="medicalCenterAddress3"
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name="medicalCenterAddress3" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Address3" />
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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 Country}" />
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<select name="mccountry" id="mccountry" 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="#{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="#{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="Medical Center Licence" />
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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 Stamp}" />
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<input type="file" class="form-control" id="medicalCenterStamp"
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name="medicalCenterStamp" 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-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="#{Destination}" /> <input
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type="text" class="form-control" id="destination"
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name="destination" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Destination" />
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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="phoneNo" name="phoneNo"
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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="#{Email}" /> <input
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type="text" class="form-control" id="email" name="email"
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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="picProofOfIdentity"
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name="picProofOfIdentity" 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-6 col-lg-6 mb-3 mt-3">
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<input type="file" class="form-control" id="uploadOwnerPIC"
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name="uploadOwnerPIC" autofocus="autofocus" /> <img
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src="https://placeimg.com/640/480/any"
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class="col-sm-12 col-md-6 col-lg-6 mb-3 mt-3" /> <br /> <label><bst:radio
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name="caRadios" value="C" /> <th:block
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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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<h5>Opening Hours</h5>
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<div class="row">
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<div class="col-sm-12">
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<div class="row">
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<div class="col-sm-12 col-md-12 col-lg-12 mb-3">
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<label class="required mb-1" th:text="#{Week Days}" />
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<div class="d-flex w-100">
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<div class="mr-2 w-100">
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<select name="weekDaysFrom" id="weekDaysFrom"
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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="w-100">
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<select name="weekDaysTo" id="weekDaysTo"
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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>
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</div>
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<div class="col-sm-12 col-md-12 col-lg-12 mb-3">
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<label class="required mb-1" th:text="#{Week Days}" />
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<div class="d-flex w-100">
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<div class="mr-2 w-100">
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<select name="weekDaysFrom2" id="weekDaysFrom2"
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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="w-100">
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<select name="weekDaysTo2" id="weekDaysTo2"
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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>
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</div>
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</div>
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</div>
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</div>
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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 Destination}" /> <input
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type="text" class="form-control" id="picDestination"
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name="picDestination" autofocus="autofocus"
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onkeyup="javascript:this.value=this.value.toLowerCase();"
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placeholder="Phone Destination" />
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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="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 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="picProofOfIdentitys"
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name="picProofOfIdentitys" 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 mt-4 mb-2">
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<div class="form-group row">
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<div class="col-sm-6 mb-3">
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<h2>Add Doctor</h2>
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</div>
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<div class="col-sm-6 text-right mb-3">
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<button type="button" class="btn btn-primary"
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id="btndoctorpoup">+ Add Doctor</button>
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</div>
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<div class="table-responsive">
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<table class="table table-striped">
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<thead>
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<tr>
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<th>Doctor Name</th>
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<th>ID</th>
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<th>Destination</th>
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<th>Email</th>
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<th>Mobile No</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td>Doctor Name</td>
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<td>ID</td>
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<td>Destination</td>
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<td>Email</td>
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<td>Mobile No</td>
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</tr>
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<tr>
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<td>Doctor Name</td>
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<td>ID</td>
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<td>Destination</td>
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<td>Email</td>
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<td>Mobile No</td>
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</tr>
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<tr>
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<td>Doctor Name</td>
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<td>ID</td>
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<td>Destination</td>
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<td>Email</td>
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<td>Mobile No</td>
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</tr>
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</tbody>
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</table>
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</div>
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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="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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