Current File : /home/inlingua/www/sensoriumpsychologists.com/backup/diagnostics/franchise_registration.php |
<!DOCTYPE html>
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<!--[if gt IE 8]><!--> <html class="no-js"> <!--<![endif]-->
<head>
<title>Franchise Registration</title>
<?php include("common/head_links.php");?>
</head>
<body class="theme_skin_kinder">
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<div id="box_wrapper">
<?php include("common/header.php");?>
<section id="topOfPage" class="topTabsWrap color_section">
<div class="container">
<div class="row">
<div class="col-sm-12">
<h3 class="pageTitle h3">Franchise Registration</h3>
</div>
</div>
</div>
</section>
<section class="mainWrap">
<div class="container">
<div class="row">
<div class="col-sm-12">
<h3 class="title">Registration Now</h3>
<div class="sc_contact_form sc_contact_form_contact" style="border:1px solid #00F; padding:25px;">
<form data-formtype="contact" method="post" action="">
<div class="columnsWrap">
<div class="col-md-4">
<label class="required" for="">Name</label>
<input id="" type="text" name="name">
</div>
<div class="col-md-4">
<label class="required" for="">E-mail</label>
<input id="" type="text" name="email">
</div>
<div class="col-md-4">
<label class="required" for="">Mobile No.</label>
<input id="" type="text" name="mobile">
</div>
</div>
<div class="columnsWrap">
<div class="col-md-4">
<label class="required" for="">Office No.</label>
<input id="" type="text" name="office_no">
</div>
<div class="col-md-8">
<label class="required" for="">Address</label>
<input id="" type="text" name="address">
</div>
</div>
<div class="message">
<label class="required" for="">Educational Qualification Promoter/Partner/Individual</label>
<textarea id="" class="textAreaSize" name="educational_qualification"></textarea>
</div>
<div class="message">
<label class="required" for="">Institute</label>
<textarea id="" class="textAreaSize" name="institute"></textarea>
</div>
<div class="columnsWrap">
<div class="col-md-4">
<label class="required" for="">PAN No.</label>
<input id="" type="text" name="pan_no">
</div>
<div class="col-md-4">
<label class="required" for="">Occupation</label>
<input id="" type="text" name="occupation">
</div>
<div class="col-md-4">
<label class="required" for="">Nature of Work</label>
<input id="" type="text" name="nature_of_work">
</div>
</div>
<div class="columnsWrap">
<h3>For Persons In Business</h3>
<div class="col-md-4">
<label class="required" for="">Company Name(s)</label>
<input id="" type="text" name="">
</div>
<div class="col-md-4">
<label class="required" for="">Ownership Prop./Pvt. Partner</label>
<input id="" type="text" name="">
</div>
<div class="col-md-4">
<label class="required" for="">Nature of Business</label>
<input id="" type="text" name="">
</div>
</div>
<div class="columnsWrap">
<h3></h3>
<div class="col-md-4">
<label class="required" for="">Principal Product/Brand</label>
<input id="" type="text" name="">
</div>
<div class="col-md-4">
<label class="required" for="">Years in Business</label>
<input id="" type="text" name="">
</div>
<div class="col-md-4">
<label class="required" for="">Annual Turnover (Current Fiscal YR)</label>
<input id="" type="text" name="">
</div>
</div>
<div class="columnsWrap">
<h3>For Persons In Service</h3>
<div class="col-md-4">
<label class="required" for="">Name of Current Employer</label>
<input id="" type="text" name="">
</div>
<div class="col-md-4">
<label class="required" for="">Designation</label>
<input id="" type="text" name="">
</div>
<div class="col-md-4">
<label class="required" for="">Job Profile</label>
<input id="" type="text" name="">
</div>
</div>
<div class="columnsWrap">
<h3>Franchise Details</h3>
<h4>Existing Franchise Details</h4>
<div class="col-md-2">
<label class="required" for="">City for Franchise</label>
<input id="" type="text" name="">
</div>
<div class="col-md-2">
<label class="required" for="">Location</label>
<input id="" type="text" name="">
</div>
<div class="col-md-2">
<label class="required" for="">Area (In Square Feets)</label>
<input id="" type="text" name="">
</div>
<div class="col-md-3">
<label class="required" for="">Area on Hire/Lease/Loan</label>
<input id="" type="text" name="">
</div>
<div class="col-md-3">
<label class="required" for="">Prop. / Partnership / Pvt. Ltd.</label>
<input id="" type="text" name="">
</div>
</div>
<div class="columnsWrap">
<h4>Proposed Franchise Details</h4>
<div class="col-md-2">
<label class="required" for="">Intersted City for Franchise</label>
<input id="" type="text" name="">
</div>
<div class="col-md-2">
<label class="required" for="">Proposed Location</label>
<input id="" type="text" name="">
</div>
<div class="col-md-2">
<label class="required" for="">Area (In Square Feets)</label>
<input id="" type="text" name="">
</div>
<div class="col-md-3">
<label class="required" for="">Area on Hire/Lease/Loan</label>
<input id="" type="text" name="">
</div>
<div class="col-md-3">
<label class="required" for="">Prop. / Partnership / Pvt. Ltd.</label>
<input id="" type="text" name="">
</div>
</div>
<div class="columnsWrap">
<h4>How soon you can start the project</h4>
<div class="col-md-3">
<label class="required" for="">One Month/Two Months/Three Months</label>
</div>
<div class="col-md-3">
<input id="" type="text" name="">
</div>
<div class="col-md-3">
<label class="required" for="">Amount</label>
</div>
<div class="col-md-3">
<input id="" type="text" name="">
</div>
</div>
<div class="sc_contact_form_button">
<div class="squareButton ico">
<a href="#" class="sc_contact_form_submit icon-comment">Next</a>
</div>
</div>
<div class="result sc_infobox"></div>
</form>
</div>
<!-- <form>
<div class="form-group">
<input type="text" class="form-control" id="name" placeholder="Your Name">
</div>
<div class="form-group">
<label for="mobile">Mobile Number:</label>
<input type="text" class="form-control" id="mobile">
</div>
<div class="form-group">
<label for="email">Email ID:</label>
<input type="email" class="form-control" id="email">
</div>
<div class="form-group">
<label for="pwd">Password:</label>
<input type="password" class="form-control" id="pwd">
</div>
<div class="form-group">
<label for="pwd">Retype Password:</label>
<input type="password" class="form-control" id="pwd">
</div>
<div>
<span><img src="captcha.php" alt="Captcha" /> </span><br /><br />
</div>
<div class="form-group">
<label for="mobile">Enter Captcha Code</label>
<input type="text" class="form-control" id="mobile">
</div>
<div class="checkbox">
<label><input type="checkbox"> </i>I accept all <a class="terms" href="#">terms and conditions</a></label>
</div>
<button type="submit" class="btn btn-success pull-right">Create an Account</button>
</form>-->
</div>
</div>
</div>
</section>
<?php include("common/footer.php");?>
</div><!-- eof #box_wrapper -->
<div class="preloader">
<div class="preloader_image"></div>
</div>
<?php include("common/footer_links.php");?>
</body>
</html>