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  • Registration Form Agent Agent Code: Name: Date of Birth: Address

    Uploaded by

    Aishah amslah
    8 views2 pages
    Daaru salaam university

    Original Title

    agent

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Daaru salaam university

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views2 pages

    Registration Form Agent Agent Code: Name: Date of Birth: Address

    Uploaded by

    Aishah amslah
    Daaru salaam university

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

     

    <html>

    <head>

    <title>Registration Form</title>

    </head>

    <body>

    <link href = "registration.css" type = "text/css" rel = "stylesheet" />

    <h2>Agent</h2>

    <form name = "form1" action='modified.php' method = 'POST' enctype =


    "multipart/form-data" >

    <div class = "container">

    <div class = "form_group">

    <label>Agent Code:</label>

    <input type = "text" name = "Agent_code" required pattern="[0-


    9]{3}[A-Z a-z]{3}[0-9]{3}"/>

    </div>

    <div class = "form_group">

    <label>Name:</label>

    <input type = "text" name = "Agent_Name" value = "" required />

    </div>

    <div class = "form_group">

    <label>Date of Birth: </label><input type = "date" name =


    "DOB" value = "" required />

    </div>

    <div class = "form_group">

    <label>Address:</label>

    <input type = "text" name = "Address" value = "" required />

    </div>

    <div class = "form_group">


    <label>Pincode: </label>

    <input type = "text" name = "Pincode" value = "" required />

    </div>

    <div class = "form_group">

    <label>Branch: </label>

    <input type = "text" name = "Branch" value = "" required" />

    </div>

    <div class = "form_group">

    <label>Contact Number: </label>

    <input type = "text" name = "Contact_Number" value = ""


    required pattern="[0-9]{10}" />

    </div>

    <div class = "form_group">

    <input type = "submit" value = "submit"/>

    </div>

    <div class = "form_group">

    <input type = "reset" value = "reset"/>

    </div>

    <div class = "form_group">

    <label><a href="../index.php">Back to homepage</a></label>

    </div>

    </div>

    </form>

    </body>

    </html>

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