register.cultcon.in Open in urlscan Pro
103.129.97.67  Public Scan

Form analysis
1 forms found in the DOM

POST

<form method="post" action="" id="register_form">
  <h3 class="text-center pb-0 py-3">Register Now</h3>
  <div class="row">
    <div class="col-lg-12">
    </div>
    <div class="row">
      <table class="w-100 text-center table table-bordered">
        <thead class="bg-primary text-light">
          <tr>
            <th>Surgeon/ Doctor</th>
            <th>Post Graduate student</th>
          </tr>
        </thead>
        <tbody>
          <tr>
            <td>₹ 5000/-</td>
            <td>₹ 3500/-</td>
          </tr>
        </tbody>
      </table>
      <div class="col-6 mb-4">
        <div class="form-check">
          <input class="form-check-input check-reg-type" data-key="REGISTRATION_TYPE" required="" type="radio" value="Surgeon/Doctor" name="register_type" id="register_type_surgeon" onclick="updateAmount()">
          <label class="form-check-label" for="register_type_surgeon"> Surgeon/ Doctor </label>
        </div>
      </div>
      <div class="col-6 mb-4">
        <div class="form-check">
          <input class="form-check-input check-reg-type" data-key="REGISTRATION_TYPE" required="" type="radio" value="Post Graduate student" name="register_type" id="register_type_student" onclick="updateAmount()">
          <label class="form-check-label" for="register_type_student"> Post Graduate student </label>
        </div>
      </div>
    </div>
    <div class="col-lg-6 ">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i aria-hidden="true" class="fa fa-user"></i>
            </div>
          </div>
          <input type="text" name="f_name" placeholder="First Name" required="" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i aria-hidden="true" class="fa fa-user"></i>
            </div>
          </div>
          <input type="text" name="l_name" placeholder="Last Name" required="" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i class="fas fa-pen-nib"></i>
            </div>
          </div>
          <input type="text" name="qualifications" placeholder="Qualifications" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i class="fas fa-pen-nib"></i>
            </div>
          </div>
          <input type="text" name="designation" placeholder="Designation" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <select name="std_code" id="std_code" disable="" class="bg-light border-0">
                <option>91</option>
              </select>
            </div>
          </div>
          <input type="number" id="mobile_code" class="form-control" placeholder="Phone Number" required="" name="phone">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i aria-hidden="true" class="fa fa-envelope"></i>
            </div>
          </div>
          <input type="email" name="email" class="form-control" placeholder="Email" required="">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i class="fas fa-caret-down"></i>
            </div>
          </div>
          <input type="text" name="city" placeholder="City" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i class="fas fa-map-marked-alt"></i>
            </div>
          </div>
          <input type="text" name="address" placeholder="Address" required="" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-6">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i class="fas fa-map-marked-alt"></i>
            </div>
          </div>
          <input type="text" name="ins" placeholder="Affiliated Hospital / Institution" required="" class="form-control">
        </div>
      </div>
    </div>
    <div class="col-lg-12">
      <div class="form-group mb-2">
        <div class="input-group mb-3">
          <div class="input-group-prepend">
            <div class="input-group-text" style="height:100%;">
              <i class="fas fa-caret-down"></i>
            </div>
          </div>
          <select name="workshop" id="workshop" required="" class="form-control">
            <option value="" hidden="">Work Shop Registration required? (50 seats only. Fees Rs 1500)</option>
            <option value="Yes"> Yes</option>
            <option value="No Workshop"> No </option>
          </select>
        </div>
      </div>
    </div>
    <div class="col-lg-8 mt-2">
      <div class="text-center" style="padding-top:20px;">
        <table class="table w-75 m-auto">
          <tbody>
            <tr>
              <td style="width:50%; font-weight:700;">Amount: </td>
              <td style="width:50%;" id="reg_type_fees">₹0</td>
            </tr>
            <tr>
              <td style="width:50%; font-weight:700;">Workshop Fees : </td>
              <td style="width:50%;">
                <span id="workshop_fees">₹0</span>
              </td>
            </tr>
            <!--  <tr>
                                        <td Style="width:50%; font-weight:700;">18% GST :  </td>
                                        <td Style="width:50%;">
                                            <span id="bank_fees">
                                                ₹ 0                                            </span>
                                        </td>
                                    </tr>-->
            <tr>
              <td style="width:50%; font-weight:700;">Total Conference Fees : </td>
              <td style="width:50%;">
                <span id="total_amount">₹0</span>
              </td>
            </tr>
          </tbody>
        </table>
      </div>
    </div>
    <input type="hidden" id="reg_amount" name="reg_amount" value="0">
    <div class="col-lg-12 mt-2 text-center alert-success" id="success-message" style="display: none;">Registration Successful! Confirmation Email Sent!</div>
    <div class="col-lg-12">
      <div class="text-center mt-3" id="msg"></div>
      <input class="btn w-100 btn-primary" type="submit" id="sumt" name="submit" value="Register Now">
      <br>
      <p class="text-center"><b>Note : </b>Please check <b>Inbox / Spam</b> folder for the confirmation email.</p>
    </div>
  </div>
</form>

Text Content

REGISTER NOW

Surgeon/ Doctor Post Graduate student ₹ 5000/- ₹ 3500/-

Surgeon/ Doctor
Post Graduate student




91





Work Shop Registration required? (50 seats only. Fees Rs 1500) Yes No

Amount: ₹0 Workshop Fees : ₹0 Total Conference Fees : ₹0

Registration Successful! Confirmation Email Sent!



Note : Please check Inbox / Spam folder for the confirmation email.

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