Subversion Repositories SmartDukaan

<script src="<?=base_url().$this->config->item('current_client')?>/js/fos.js?version=<?=$this->config->item('cdn_version');?>" type="text/javascript"></script>

<div class="shipping-cont">

  <div id="error" class="error_msg" <?php if(isset($signup['msg']) && !empty($signup['msg'])){ ?>style="display:block" <?php } else {?> style="display:none" <?php }?>>

    <?php if(isset($signup['msg']) && !empty($signup['msg'])){

      echo $signup['msg'];

      } ?>

  </div>   

  <form method="POST" action="<?php base_url().'fos/signupcounter';?>" onsubmit="return counterform()" class="address-form" <?php if(isset($addresses->addresses) && !empty($addresses->addresses)) {?> style="display:none" <?php } else{?> style="display:block" <?php }?>>

    <fieldset>

      <label>Name<span>*</span></label>

      <input type="text" id="name" name="name"/>

      <label>Counter Name<span>*</span></label>

      <input type="text" id="countername" name="countername"/>

      <label>Tin Number<span>*</span></label>

      <input type="text" id="tin" name="tin"/>

      <label>Address Line 1<span>*</span></label>

      <input type="text" id="line1" name="address1"/>

      <label>Address Line 2</label>

      <input type="text" id="line2" name="address2"/>

      <label>Area</label>

      <input type="text" id="area" name="area"/>

      <label>City<span>*</span></label>

      <select id="city" name="city">

        <option value="Hyderabad">Hyderabad</option>

        <option value="Secunderabad">Secunderabad</option>

      </select>

      <label>State<span>*</span></label>

      <select id="state" name="state">

        <option value="Telangana">Telangana</option>        

      </select>

      <label>Pincode<span>*</span></label>

      <input type="number" id="pin" name="pincode"/>

      <label>Email<span>*</span></label>

      <input type="text" id="email" name="email"/>

      <label>Mobile Number<span>*</span></label>

      <input maxlength="12" type="number" id="phone" name="mobile"/>

      <label>Alternate Mobile Number<span>*</span></label>

      <input maxlength="12" type="number" id="alternatemobile" name="alternatemobile"/>

      <label>DOB</label>

      <input type="date" id="date" name="dob"/>

      <label>Counter Size (SP)</label>

      <input type="number" id="spcountersize" name="spcountersize"/>

      <label>Counter Size (FP)</label>

      <input type="number" id="fpcountersize" name="fpcountersize"/>

      <label>Striker</label>

      <input type="checkbox" id="striker" name="striker" value="1"/>

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

    </fieldset>

  </form>