0xV3NOMx
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


Current Path : /proc/thread-self/root/var/www/html/gcg/adm_useless/
Upload File :
Current File : //proc/thread-self/root/var/www/html/gcg/adm_useless/admAppForm.html

<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>