Linux ip-172-26-7-228 5.4.0-1103-aws #111~18.04.1-Ubuntu SMP Tue May 23 20:04:10 UTC 2023 x86_64
Your IP : 3.149.238.67
<div class="row clearfix" id = "personal_det">
<div class="col-lg-10 col-md-10 col-sm-12 col-xs-12 m-l--50">
<div class="card">
<div class="header">
<h2>PERSONAL INFORMATION</h2>
<span class="pull-right">
<b>Step 1 of 3</b>
</span>
</div>
<div class="body">
<div class="col-md-5">
<b>Full Name</b>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control date" placeholder="Full Name">
</div>
</div>
</div>
<div class="col-md-3">
<form action="upload.php" id="frmFileUpload" class="dropzone" method="post" enctype="multipart/form-data">
<div class="dz-message">
</div>
<div class="fallback">
<input name="file" type="file"/>
</div>
<div id="uploadedImage">
</div>
</form>
</div>
<div class="col-md-5">
<b>Name of the Father/Guardian</b>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control date" placeholder="Full Name">
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-6">
<b>Gender</b>
<div class="demo-radio-button">
<input name="group1" type="radio" id="radio_1" checked />
<label for="radio_1">Male</label>
<input name="group1" type="radio" id="radio_2" />
<label for="radio_2">Female</label>
<input name="group1" type="radio" id="radio_3" />
<label for="radio_3">Transgender</label>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-6">
<b>Handicap</b>
<div class="demo-radio-button">
<input name="group2" type="radio" id="radio_4" checked />
<label for="radio_4">None</label>
<input name="group2" type="radio" id="radio_5" />
<label for="radio_5">PHC</label>
<input name="group2" type="radio" id="radio_6" />
<label for="radio_6">VHC</label>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Date Of Birth</b>
<div class="form-group">
<div class="form-line daterange">
<input type="text" class="form-control date" id="dob" placeholder="dd/mm/yyyy">
</div>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Category</b>
<select id="status" class="form-control show-tick">
<option value="">-- Select Category --</option>
<option value="GM">General Merit</option>
<option value="CAT-1">Catgory-1</option>
<option value="CAT-2">Catgory-2</option>
<option value="CAT-3">Catgory-3</option>
<option value="CAT-4">Catgory-4</option>
<option value="SC">Scheduled Caste</option>
<option value="ST">Scheduled Tribes</option>
</select>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Aadhar Number</b>
<div class="form-group">
<div class="form-line">
<input type="text" id="adhar" class="form-control" placeholder="Aadhar Number">
</div>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-6">
<b>Handicap</b>
<div class="demo-radio-button">
<input name="group3" type="radio" id="indian" checked />
<label for="indian">Indian</label>
<input name="group3" type="radio" id="others" />
<label for="others">Others</label>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Address</b>
<div class="form-group p-b-10">
<div class="form-line">
<input type="text" class="form-control" placeholder="Address Line - 1">
</div>
</div>
<div class="form-group p-b-10">
<div class="form-line">
<input type="text" class="form-control" placeholder="Address Line - 2">
</div>
</div>
<div class="form-group p-b-10">
<div class="form-line">
<input type="text" class="form-control" placeholder="Address Line - 3">
</div>
</div>
<div class="form-group p-b-10 m-l--15 col-md-6">
<div class="form-line">
<input type="text" class="form-control" placeholder="District">
</div>
</div>
<div class="form-group pull-right m-r--15 col-md-6">
<div class="form-line">
<input type="text" class="form-control" placeholder="Pincode">
</div>
</div>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control" placeholder="State">
</div>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Phone Numbers</b>
<div class="form-group p-b-10">
<div class="form-line">
<input type="text" id="mobile" class="form-control" placeholder="Mobile">
</div>
</div>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control" placeholder="Land Line (Optional)">
</div>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Email Address</b>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control" id="email" placeholder="Email Address">
</div>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Occupation</b>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control" id="ocupation" placeholder="Occupation">
</div>
</div>
</div>
</div>
<div class="row clearfix">
<div class="col-md-5">
<b>Annual Income</b>
<div class="form-group">
<div class="form-line">
<input type="text" class="form-control" id="income" placeholder="Income">
</div>
</div>
</div>
</div>
</div>
<div class="footer">
<button type="button" class="btn btn-primary waves-effect btn-lg" onclick = "SaveApplicationDetails()">Next</button>
</div>
</div>
</div>
</div>
<script type="text/javascript">
$('#statusDetl').addClass("hidden");
var $demoMaskedInput = $('.daterange');
//Date
$demoMaskedInput.find('.date').inputmask('dd/mm/yyyy', { placeholder: '__/__/____' });
$('#adhar').inputmask('9999 9999 9999', { placeholder: '____ ____ ____' });
$('#mobile').inputmask('+99 (999) 999-99-99', { placeholder: '+__ (___) ___-__-__' });
$('#email').inputmask({ alias: "email" });
//$('#income').inputmask('99,99 €', { placeholder: '__,__ €' });
$("#S4").keypress(function (e){
var key = e.which;
if(key == 13) // the enter key code
{
getDetails();
}
});
$(document).ready(function () {
var inputs = $('input, select').keypress(function (e) {
if (e.which == 13) {
e.preventDefault();
var nextInput = inputs.get(inputs.index(this) + 1);
if (nextInput) {
nextInput.focus();
}
}
});
});
</script>
<script src="js/pages/forms/form-wizard.js"></script>
<script src="js/pages/forms/advanced-form-elements.js"></script>
<!-- Autosize Plugin Js -->
<script src="js/form_submit.js"></script>
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