136 lines
6.4 KiB
Plaintext
136 lines
6.4 KiB
Plaintext
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8" />
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<meta name="viewport" content="width=device-width, initial-scale=1.0" />
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<title>VA Registration</title>
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<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.2/dist/css/bootstrap.min.css">
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<!-- Custom CSS -->
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<link rel="stylesheet" href="/public/css/va-register.css">
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</head>
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<body>
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<section class="h-100">
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<div class="container py-1">
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<div class="row d-flex justify-content-center align-items-center">
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<div class="col">
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<div class="card card-registration my-4 shadow">
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<div class="row g-0">
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<!-- Left Side Image -->
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<div class="col-xl-6 d-none d-xl-block">
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<img
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src="https://mdbcdn.b-cdn.net/img/Photos/new-templates/bootstrap-registration/img4.webp"
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alt="Registration Image"
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class="img-fluid"
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style="border-top-left-radius: .25rem; border-bottom-left-radius: .25rem;"
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/>
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</div>
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<!-- Right Side Form -->
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<div class="col-xl-6">
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<div class="card-body p-md-5 text-black">
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<h3 class="mb-5 text-uppercase text-center">Virtual Assistant Registration</h3>
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<form id="vaForm">
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<div class="row">
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<div class="col-md-6 mb-4">
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<div class="form-outline">
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<input type="text" id="firstName" name="userDetails[firstName]" class="form-control form-control-lg" required />
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<label class="form-label" for="firstName">First Name *</label>
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</div>
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</div>
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<div class="col-md-6 mb-4">
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<div class="form-outline">
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<input type="text" id="lastName" name="userDetails[lastName]" class="form-control form-control-lg" required/>
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<label class="form-label" for="lastName">Last Name</label>
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</div>
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</div>
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</div>
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<div class="form-outline mb-4">
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<input type="email" id="email" name="userDetails[email]" class="form-control form-control-lg" required />
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<label class="form-label" for="email">Email *</label>
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</div>
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<div class="row">
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<div class="col-md-6 mb-4">
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<div class="form-outline">
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<input type="text" id="age" name="userDetails[age]" class="form-control form-control-lg not-required" placeholder=""/>
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<label class="form-label" for="age">Age</label>
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</div>
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</div>
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<div class="col-md-6 mb-4">
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<div class="form-outline">
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<input type="date" id="dob" name="userDetails[dob]" class="form-control form-control-lg" />
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<label class="form-label" for="dob">Date of Birth</label>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6 mb-4">
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<div class="form-outline">
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<input type="password" id="password" name="userDetails[password]" class="form-control form-control-lg" required />
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<label class="form-label" for="password">Password *</label>
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</div>
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</div>
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<div class="col-md-6 mb-4">
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<div class="form-outline">
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<input type="password" id="cPassword" name="userDetails[cPassword]" class="form-control form-control-lg" required />
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<label class="form-label" for="cPassword">Confirm Password *</label>
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</div>
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</div>
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</div>
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<div class="form-outline mb-4">
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<input type="text" id="address" name="userDetails[address]" class="form-control form-control-lg not-required" placeholder=""/>
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<label class="form-label" for="address">Address</label>
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</div>
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<h5 class="mt-4 mb-3">Bank Details</h5>
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<div class="form-outline mb-4">
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<input type="text" id="bankName" name="userDetails[bankName]" class="form-control form-control-lg" required/>
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<label class="form-label" for="bankName">Bank Name</label>
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</div>
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<div class="form-outline mb-4">
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<input type="text" id="accountHolderName" name="userDetails[accountHolderName]" class="form-control form-control-lg" required/>
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<label class="form-label" for="accountHolderName">Account Holder Name</label>
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</div>
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<div class="form-outline mb-4">
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<input type="text" id="accountNumber" name="userDetails[accountNumber]" class="form-control form-control-lg" required/>
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<label class="form-label" for="accountNumber">Account Number</label>
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</div>
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<div class="form-outline mb-4">
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<input type="text" id="routingNumber" name="userDetails[routingNumber]" class="form-control form-control-lg" required/>
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<label class="form-label" for="routingNumber">Routing Number</label>
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</div>
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<div class="mb-4">
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<label class="form-label" for="status">Status</label>
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<select id="status" name="status" class="form-select form-select-lg">
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<option value="FULLTIME">Full-Time</option>
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<option value="PARTTIME">Part-Time</option>
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</select>
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</div>
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<div class="d-flex justify-content-end pt-3">
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<button type="reset" class="btn btn-light btn-lg">Reset all</button>
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<button type="submit" class="btn btn-warning btn-lg ms-2">Submit form</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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</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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</section>
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<!-- Custom JS -->
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<script src="/public/js/va-register.js"></script>
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</body>
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</html>
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