cool10.vimi50.site
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urlscan Pro
216.185.57.104
Public Scan
Submitted URL: https://cool10.vimi50.site/
Effective URL: https://cool10.vimi50.site/login
Submission: On November 10 via api from US — Scanned from DE
Effective URL: https://cool10.vimi50.site/login
Submission: On November 10 via api from US — Scanned from DE
Form analysis 11 forms found in the DOM
POST https://cool10.vimi50.site/login
<form method="POST" action="https://cool10.vimi50.site/login" id="login_form">
<input type="hidden" name="_token" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<div class="mb-3 flex p-4 mx-2 bg-gray-200 rounded">
<input class="w-full text-xs bg-gray-200 outline-none " id="email" type="text" placeholder="name@email.com" name="username" value="" required="" autocomplete="email" autofocus="">
<svg class="h-6 w-6 ml-4 my-auto text-gray-300" xmlns="http://www.w3.org/2000/svg" fill="none" viewBox="0 0 24 24" stroke="currentColor">
<path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M16 12a4 4 0 10-8 0 4 4 0 008 0zm0 0v1.5a2.5 2.5 0 005 0V12a9 9 0 10-9 9m4.5-1.206a8.959 8.959 0 01-4.5 1.207">
</path>
</svg>
</div>
<div class="mb-2 flex p-4 mx-2 bg-gray-200 rounded">
<input class="w-full text-xs bg-gray-200 outline-none " id="password" type="password" placeholder="Enter your password" name="password" required="" autocomplete="current-password">
<svg class="h-6 w-6 ml-4 my-auto text-gray-300" xmlns="http://www.w3.org/2000/svg" onmouseover="mouseoverPass();" onmouseout="mouseoutPass();" fill="none" viewBox="0 0 24 24" stroke="currentColor">
<path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M15 12a3 3 0 11-6 0 3 3 0 016 0z"></path>
<path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M2.458 12C3.732 7.943 7.523 5 12 5c4.478 0 8.268 2.943 9.542 7-1.274 4.057-5.064 7-9.542 7-4.477 0-8.268-2.943-9.542-7z">
</path>
</svg>
</div>
<p class="mb-4 ml-3 text-xs text-gray-400"><a class="underline hover:text-gray-500" href="https://cool10.vimi50.site/password/reset">
Forgot Your Password?
</a></p>
<hr>
<div class="px-3 text-center">
<button class="mb-2 w-full py-4 bg-purple-600 shadow-lg hover:bg-purple-700 rounded text-sm font-bold text-gray-50 transition duration-200">Sign In</button>
<span class="text-gray-400 text-xs">
<span>If you do not have an account?</span>
<a data-toggle="modal" data-target="#check_register_type_modal" class="text-purple-600 hover:underline signup-button" href="#">Sign Up</a>
</span>
</div>
</form>POST https://cool10.vimi50.site/post-repair-status
<form method="POST" action="https://cool10.vimi50.site/post-repair-status" id="check_repair_status">
<div class="form-group">
<select class="form-control width-60 pull-left" name="search_type">
<option value="job_sheet_no">Job sheet number</option>
<option value="invoice_no">Invoice No.</option>
<option value="vehicle_no">Vehicle No</option>
<option value="mobile_num">Mobile Number</option>
</select>
</div>
<div class="form-group">
<input class="form-control width-40 pull-left" required="" placeholder="Job sheet no. / Invoice no. / Vehicle No / Mobile Number" name="search_number" type="text">
</div>
<div class="form-group">
<div class="input-group">
<input type="text" name="serial_no" class="form-control" id="repair_serial_no" placeholder="Serial Number">
</div>
</div>
<div class="form-group">
<button type="submit" class="btn-login btn btn-primary btn-flat ladda-button"> Search </button>
</div>
</form>POST https://cool10.vimi50.site/vehicle
<form method="POST" action="https://cool10.vimi50.site/vehicle">
<input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<style>
.vehicle-register-wrap label {
color: #000 !important;
}
.sa-innate-form input[type=text],
input[type=password],
input[type=file],
textarea,
select,
email {
font-size: 13px;
padding: 10px;
border: 1px solid#ccc;
outline: none;
width: 100%;
margin: 0px;
}
</style>
<div class="row vehicle-register-wrap">
<div class="col-md-12">
<div class="box box-solid">
<div class="box-header with-border">
<h3 class="box-title pull-left">REGISTER YOUR VEHICLE</h3>
</div>
<!-- /.box-header -->
<div class="box-body">
<div class="row">
<div class="col-md-3">
<div class="form-group">
<label for="number">Vehicle No:</label>
<div>
<input class="form-control" placeholder="Vehicle No" required="" name="number" type="text" id="number">
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="vehicle_category_id">Vehicle Category:</label>
<div>
<select id="vehicle_category_id" class="form-control" required="" name="vehicle_category_id">
<option selected="selected" value="">Please Select</option>
</select>
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="fuel_type_id">Fuel Type:</label>
<div>
<select class="form-control" required="" id="fuel_type_id" name="fuel_type_id">
<option selected="selected" value="">Please Select</option>
</select>
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="r_name">Vehicle Name:</label>
<div>
<input class="form-control" placeholder="Vehicle Name" required="" id="r_name" autocomplete="on" name="name" type="text">
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-3">
<div class="form-group">
<label for="r_district_id">District:</label>
<div>
<select class="form-control" required="" id="r_district_id" name="district_id">
<option selected="selected" value="">Please Select</option>
</select>
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="r_town">Town:</label>
<div>
<input class="form-control" placeholder="Town" required="" id="r_town" name="town" type="text">
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="r_mobile">Mobile No:</label>
<div>
<input class="form-control" placeholder="Mobile No" required="" id="r_mobile" name="mobile" type="text">
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="v_landline">Land Line No:</label>
<div>
<input class="form-control" placeholder="Land Line No" id="v_landline" name="landline" type="text">
</div>
</div>
</div>
</div>
<div class="col-md-12">
<hr>
</div>
<div class="row">
<div class="col-md-3">
<div class="form-group">
<label for="image">Image:</label>
<div>
<input name="image" type="file" id="image">
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="passcode">Passcode:</label>
<div>
<input class="form-control" placeholder="Passcode" readonly="" required="" name="passcode" type="text" value="88774" id="passcode">
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="r_password">Password:</label>
<div>
<input class="form-control" placeholder="Password" required="" id="r_password" name="password" type="password" value="">
</div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<label for="created_at">Date:</label>
<div>
<input class="form-control " placeholder="Date" readonly="" required="" name="created_at" type="text" value="2024-11-10" id="created_at">
</div>
</div>
</div>
</div>
</div>
<!-- /.box-body -->
<div class="box-footer">
<button type="submit" class="btn btn-success pull-right">Register</button>
</div>
</div>
<!-- /.box -->
</div>
</div>
</form>POST https://cool10.vimi50.site/business/visitor-register
<form method="POST" action="https://cool10.vimi50.site/business/visitor-register" accept-charset="UTF-8" id="visitor_register_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<p class="form-header">Register and Get Started in minutes</p>
<h3>Business</h3>
<input name="language" type="hidden">
<style>
.wizard>.content {
background: {
{
$login_background_color
}
}
!important;
}
label {
text-align: left;
color: white !important;
}
.select2-results__option[aria-selected="true"] {
display: none;
}
.equal-column {
min-height: 95px;
}
</style>
<div class="col-md-12" style="">
<div class="row">
<input type="hidden" name="option_variables_selected" class="rm_option_variables_selected">
<input type="hidden" name="module_selected" class="rm_module_selected">
<input type="hidden" name="custom_price" class="rm_custom_price">
<input class="package_id" name="package_id" type="hidden">
<div class="col-md-12">
<div class="form-group">
<label for="v_name">Business Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-suitcase"></i>
</span>
<input class="form-control" placeholder="Business Name" required="" id="v_name" autocomplete="on" name="name" type="text">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="r_f_v_mobile">Business contact number:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Business contact number" id="r_f_v_mobile" name="mobile" type="text">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="alternate_number">Alternate contact number:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Alternate contact number" name="alternate_number" type="text" id="alternate_number">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="country">Country:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-globe"></i>
</span>
<input class="form-control" placeholder="Country" required="" autocomplete="on" name="country" type="text" id="country">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="state">State:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="State" required="" name="state" type="text" id="state">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-6">
<div class="form-group">
<label for="city">City:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="City" required="" name="city" type="text" id="city">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="zip_code">Zip Code:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="Zip/Postal Code" required="" name="zip_code" type="text" id="zip_code">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="landmark">Landmark:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="Landmark" required="" name="landmark" type="text" id="landmark">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-4">
<div class="form-group">
<label for="surname">Prefix:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="Mr / Mrs / Miss" name="surname" type="text" id="surname">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="first_name">First Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="First Name" required="" autocomplete="on" name="first_name" type="text" id="first_name">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="last_name">Last Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="Last Name" name="last_name" type="text" id="last_name">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-6">
<div class="form-group">
<label for="visitor_username">Username:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Username" id="visitor_username" required="" autocomplete="on" name="username" type="text">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="visitor_email">Email:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-envelope"></i>
</span>
<input class="form-control" id="visitor_email" placeholder="Email" autocomplete="on" name="email" type="text">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-6">
<div class="form-group">
<label for="visitor_password">Password:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-lock"></i>
</span>
<input class="form-control" placeholder="Password" id="visitor_password" style="margin:0px;" required="" name="password" type="password" value="">
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="visitor_confirm_password">Confirm Password:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-lock"></i>
</span>
<input class="form-control" placeholder="Confirm Password" style="margin:0px;" required="" id="visitor_confirm_password" name="confirm_password" type="password" value="">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-6">
</div>
<div class="col-md-12">
<div class="form-group" style="padding:auto; margin-top:10px;margin-bottom:10px;">
<div class="g-recaptcha" data-sitekey="6Le0JCsdAAAAAMz-cD3AL5Xh-SOCUCaXIP8dbZmi"></div>
</div>
</div>
</div>
</div>
<p></p>
<hr>
<div class="clearfix"></div>
<div>
<button type="submit" id="visitor_form_btn" class="btn btn-primary">Submit</button>
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
</form>POST https://cool10.vimi50.site/process/verify
<form method="POST" action="https://cool10.vimi50.site/process/verify" accept-charset="UTF-8" id="verification_form"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<div class="modal-body">
<div class="row">
<div class="col-md-12">
<div class="form-group">
<input class="form-control" placeholder="Enter receaved OPT" required="" name="code" type="text">
</div>
</div>
</div>
<div class="clearfix"></div>
</div>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row" id="add-link-opt">
</div>
<div class="row">
<div class="col-md-6" style="text-align: left;">
</div>
<div class="col-md-6" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Verify</button>
</div>
</div>
</div>
</form>POST https://cool10.vimi50.site/business/register
<form method="POST" action="https://cool10.vimi50.site/business/register" accept-charset="UTF-8" id="business_register_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<h3>Business</h3>
<input name="language" type="hidden">
<style>
.label_register {
color: #000000 !important;
}
.select2-results__option[aria-selected="true"] {
display: none;
}
.equal-column {
min-height: 95px;
}
</style>
<fieldset>
<legend> </legend>
<input type="hidden" name="option_variables_selected" class="rm_option_variables_selected">
<input type="hidden" name="module_selected" class="rm_module_selected">
<input type="hidden" name="custom_price" class="rm_custom_price">
<input class="package_id" name="package_id" type="hidden">
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="b_name" class="label_register">Business Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-suitcase"></i>
</span>
<input class="form-control" placeholder="Business Name" id="b_name" required="" autocomplete="on" name="name" type="text">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="start_date" class="label_register">Start Date:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-calendar"></i>
</span>
<input class="form-control start-date-picker" placeholder="Start Date" readonly="" name="start_date" type="text" id="start_date">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="currency_id" class="label_register">Currency:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-money"></i>
</span>
<select class="form-control" style="width: 100%;" required="" id="currency_id" name="currency_id">
<option selected="selected" value="">Select Currency</option>
<option value="3">Afghanistan - Afghanis(AF) </option>
<option value="1">Albania - Leke(ALL) </option>
<option value="135">Algerie - Algerian dinar(DZD) </option>
<option value="2">America - Dollars(USD) </option>
<option value="139">Angola - Kwanza(AOA) </option>
<option value="4">Argentina - Pesos(ARS) </option>
<option value="5">Aruba - Guilders(AWG) </option>
<option value="6">Australia - Dollars(AUD) </option>
<option value="7">Azerbaijan - New Manats(AZ) </option>
<option value="8">Bahamas - Dollars(BSD) </option>
<option value="134">Bangladesh - Taka(BDT) </option>
<option value="9">Barbados - Dollars(BBD) </option>
<option value="10">Belarus - Rubles(BYR) </option>
<option value="11">Belgium - Euro(EUR) </option>
<option value="12">Beliz - Dollars(BZD) </option>
<option value="13">Bermuda - Dollars(BMD) </option>
<option value="14">Bolivia - Bolivianos(BOB) </option>
<option value="15">Bosnia and Herzegovina - Convertible Marka(BAM) </option>
<option value="16">Botswana - Pula's(BWP) </option>
<option value="18">Brazil - Reais(BRL) </option>
<option value="19">Britain [United Kingdom] - Pounds(GBP) </option>
<option value="20">Brunei Darussalam - Dollars(BND) </option>
<option value="17">Bulgaria - Leva(BG) </option>
<option value="21">Cambodia - Riels(KHR) </option>
<option value="22">Canada - Dollars(CAD) </option>
<option value="23">Cayman Islands - Dollars(KYD) </option>
<option value="24">Chile - Pesos(CLP) </option>
<option value="25">China - Yuan Renminbi(CNY) </option>
<option value="26">Colombia - Pesos(COP) </option>
<option value="27">Costa Rica - Colón(CRC) </option>
<option value="28">Croatia - Kuna(HRK) </option>
<option value="29">Cuba - Pesos(CUP) </option>
<option value="30">Cyprus - Euro(EUR) </option>
<option value="31">Czech Republic - Koruny(CZK) </option>
<option value="32">Denmark - Kroner(DKK) </option>
<option value="33">Dominican Republic - Pesos(DOP ) </option>
<option value="34">East Caribbean - Dollars(XCD) </option>
<option value="35">Egypt - Pounds(EGP) </option>
<option value="36">El Salvador - Colones(SVC) </option>
<option value="37">England [United Kingdom] - Pounds(GBP) </option>
<option value="38">Euro - Euro(EUR) </option>
<option value="39">Falkland Islands - Pounds(FKP) </option>
<option value="40">Fiji - Dollars(FJD) </option>
<option value="41">France - Euro(EUR) </option>
<option value="42">Ghana - Cedis(GHC) </option>
<option value="43">Gibraltar - Pounds(GIP) </option>
<option value="44">Greece - Euro(EUR) </option>
<option value="45">Guatemala - Quetzales(GTQ) </option>
<option value="46">Guernsey - Pounds(GGP) </option>
<option value="47">Guyana - Dollars(GYD) </option>
<option value="48">Holland [Netherlands] - Euro(EUR) </option>
<option value="49">Honduras - Lempiras(HNL) </option>
<option value="50">Hong Kong - Dollars(HKD) </option>
<option value="51">Hungary - Forint(HUF) </option>
<option value="52">Iceland - Kronur(ISK) </option>
<option value="53">India - Rupees(INR) </option>
<option value="54">Indonesia - Rupiahs(IDR) </option>
<option value="55">Iran - Rials(IRR) </option>
<option value="132">Iraq - Iraqi dinar(IQD) </option>
<option value="56">Ireland - Euro(EUR) </option>
<option value="57">Isle of Man - Pounds(IMP) </option>
<option value="58">Israel - New Shekels(ILS) </option>
<option value="59">Italy - Euro(EUR) </option>
<option value="60">Jamaica - Dollars(JMD) </option>
<option value="61">Japan - Yen(JPY) </option>
<option value="62">Jersey - Pounds(JEP) </option>
<option value="63">Kazakhstan - Tenge(KZT) </option>
<option value="133">Kenya - Kenyan shilling(KES) </option>
<option value="64">Korea [North] - Won(KPW) </option>
<option value="65">Korea [South] - Won(KRW) </option>
<option value="66">Kyrgyzstan - Soms(KGS) </option>
<option value="67">Laos - Kips(LAK) </option>
<option value="68">Latvia - Lati(LVL) </option>
<option value="69">Lebanon - Pounds(LBP) </option>
<option value="70">Liberia - Dollars(LRD) </option>
<option value="71">Liechtenstein - Switzerland Francs(CHF) </option>
<option value="72">Lithuania - Litai(LTL) </option>
<option value="73">Luxembourg - Euro(EUR) </option>
<option value="74">Macedonia - Denars(MKD) </option>
<option value="75">Malaysia - Ringgits(MYR) </option>
<option value="76">Malta - Euro(EUR) </option>
<option value="77">Mauritius - Rupees(MUR) </option>
<option value="78">Mexico - Pesos(MXN) </option>
<option value="79">Mongolia - Tugriks(MNT) </option>
<option value="80">Mozambique - Meticais(MZ) </option>
<option value="81">Namibia - Dollars(NAD) </option>
<option value="82">Nepal - Rupees(NPR) </option>
<option value="84">Netherlands - Euro(EUR) </option>
<option value="83">Netherlands Antilles - Guilders(ANG) </option>
<option value="85">New Zealand - Dollars(NZD) </option>
<option value="86">Nicaragua - Cordobas(NIO) </option>
<option value="87">Nigeria - Nairas(NG) </option>
<option value="88">North Korea - Won(KPW) </option>
<option value="89">Norway - Krone(NOK) </option>
<option value="90">Oman - Rials(OMR) </option>
<option value="91">Pakistan - Rupees(PKR) </option>
<option value="92">Panama - Balboa(PAB) </option>
<option value="93">Paraguay - Guarani(PYG) </option>
<option value="94">Peru - Nuevos Soles(PE) </option>
<option value="95">Philippines - Pesos(PHP) </option>
<option value="96">Poland - Zlotych(PL) </option>
<option value="97">Qatar - Rials(QAR) </option>
<option value="98">Romania - New Lei(RO) </option>
<option value="99">Russia - Rubles(RUB) </option>
<option value="100">Saint Helena - Pounds(SHP) </option>
<option value="101">Saudi Arabia - Riyals(SAR) </option>
<option value="102">Serbia - Dinars(RSD) </option>
<option value="103">Seychelles - Rupees(SCR) </option>
<option value="104">Singapore - Dollars(SGD) </option>
<option value="105">Slovenia - Euro(EUR) </option>
<option value="106">Solomon Islands - Dollars(SBD) </option>
<option value="107">Somalia - Shillings(SOS) </option>
<option value="108">South Africa - Rand(ZAR) </option>
<option value="109">South Korea - Won(KRW) </option>
<option value="110">Spain - Euro(EUR) </option>
<option value="111">Sri Lanka - Rupees(LKR) </option>
<option value="114">Suriname - Dollars(SRD) </option>
<option value="112">Sweden - Kronor(SEK) </option>
<option value="113">Switzerland - Francs(CHF) </option>
<option value="115">Syria - Pounds(SYP) </option>
<option value="116">Taiwan - New Dollars(TWD) </option>
<option value="138">Tanzania - Tanzanian shilling(TZS) </option>
<option value="117">Thailand - Baht(THB) </option>
<option value="118">Trinidad and Tobago - Dollars(TTD) </option>
<option value="119">Turkey - Lira(TRY) </option>
<option value="120">Turkey - Liras(TRL) </option>
<option value="121">Tuvalu - Dollars(TVD) </option>
<option value="137">Uganda - Uganda shillings(UGX) </option>
<option value="122">Ukraine - Hryvnia(UAH) </option>
<option value="136">United Arab Emirates - United Arab Emirates dirham(AED) </option>
<option value="123">United Kingdom - Pounds(GBP) </option>
<option value="124">United States of America - Dollars(USD) </option>
<option value="125">Uruguay - Pesos(UYU) </option>
<option value="126">Uzbekistan - Sums(UZS) </option>
<option value="127">Vatican City - Euro(EUR) </option>
<option value="128">Venezuela - Bolivares Fuertes(VEF) </option>
<option value="129">Vietnam - Dong(VND) </option>
<option value="130">Yemen - Rials(YER) </option>
<option value="131">Zimbabwe - Zimbabwe Dollars(ZWD) </option>
</select>
</div>
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="business_logo" class="label_register">Upload Logo:</label>
<input accept="image/*" id="business_logo" name="business_logo" type="file">
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="website" class="label_register">Website:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-globe"></i>
</span>
<input class="form-control" placeholder="Website" name="website" type="text" id="website">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="b_mobile" class="label_register">Business contact number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Business contact number" id="b_mobile" required="" name="mobile" type="text">
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="business_alternate_number" class="label_register">Alternate contact number:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Alternate contact number" id="business_alternate_number" name="alternate_number" type="text">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="business_country" class="label_register">Country:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-globe"></i>
</span>
<input class="form-control" placeholder="Country" id="business_country" required="" autocomplete="on" name="country" type="text">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="b_state" class="label_register">State:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="State" id="b_state" required="" name="state" type="text">
</div>
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="business_city" class="label_register">City:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="City" id="business_city" required="" name="city" type="text">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="b_zip_code" class="label_register">Zip Code:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="Zip/Postal Code" id="b_zip_code" required="" name="zip_code" type="text">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="b_landmark" class="label_register">Landmark:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="Landmark" required="" id="b_landmark" name="landmark" type="text">
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="time_zone" class="label_register">Time zone:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-clock-o"></i>
</span>
<select class="form-control" style="width: 100%; margin:0px;" required="" id="time_zone" name="time_zone">
<option value="">Time zone</option>
<option value="Africa/Abidjan">Africa/Abidjan</option>
<option value="Africa/Accra">Africa/Accra</option>
<option value="Africa/Addis_Ababa">Africa/Addis_Ababa</option>
<option value="Africa/Algiers">Africa/Algiers</option>
<option value="Africa/Asmara">Africa/Asmara</option>
<option value="Africa/Bamako">Africa/Bamako</option>
<option value="Africa/Bangui">Africa/Bangui</option>
<option value="Africa/Banjul">Africa/Banjul</option>
<option value="Africa/Bissau">Africa/Bissau</option>
<option value="Africa/Blantyre">Africa/Blantyre</option>
<option value="Africa/Brazzaville">Africa/Brazzaville</option>
<option value="Africa/Bujumbura">Africa/Bujumbura</option>
<option value="Africa/Cairo">Africa/Cairo</option>
<option value="Africa/Casablanca">Africa/Casablanca</option>
<option value="Africa/Ceuta">Africa/Ceuta</option>
<option value="Africa/Conakry">Africa/Conakry</option>
<option value="Africa/Dakar">Africa/Dakar</option>
<option value="Africa/Dar_es_Salaam">Africa/Dar_es_Salaam</option>
<option value="Africa/Djibouti">Africa/Djibouti</option>
<option value="Africa/Douala">Africa/Douala</option>
<option value="Africa/El_Aaiun">Africa/El_Aaiun</option>
<option value="Africa/Freetown">Africa/Freetown</option>
<option value="Africa/Gaborone">Africa/Gaborone</option>
<option value="Africa/Harare">Africa/Harare</option>
<option value="Africa/Johannesburg">Africa/Johannesburg</option>
<option value="Africa/Juba">Africa/Juba</option>
<option value="Africa/Kampala">Africa/Kampala</option>
<option value="Africa/Khartoum">Africa/Khartoum</option>
<option value="Africa/Kigali">Africa/Kigali</option>
<option value="Africa/Kinshasa">Africa/Kinshasa</option>
<option value="Africa/Lagos">Africa/Lagos</option>
<option value="Africa/Libreville">Africa/Libreville</option>
<option value="Africa/Lome">Africa/Lome</option>
<option value="Africa/Luanda">Africa/Luanda</option>
<option value="Africa/Lubumbashi">Africa/Lubumbashi</option>
<option value="Africa/Lusaka">Africa/Lusaka</option>
<option value="Africa/Malabo">Africa/Malabo</option>
<option value="Africa/Maputo">Africa/Maputo</option>
<option value="Africa/Maseru">Africa/Maseru</option>
<option value="Africa/Mbabane">Africa/Mbabane</option>
<option value="Africa/Mogadishu">Africa/Mogadishu</option>
<option value="Africa/Monrovia">Africa/Monrovia</option>
<option value="Africa/Nairobi">Africa/Nairobi</option>
<option value="Africa/Ndjamena">Africa/Ndjamena</option>
<option value="Africa/Niamey">Africa/Niamey</option>
<option value="Africa/Nouakchott">Africa/Nouakchott</option>
<option value="Africa/Ouagadougou">Africa/Ouagadougou</option>
<option value="Africa/Porto-Novo">Africa/Porto-Novo</option>
<option value="Africa/Sao_Tome">Africa/Sao_Tome</option>
<option value="Africa/Tripoli">Africa/Tripoli</option>
<option value="Africa/Tunis">Africa/Tunis</option>
<option value="Africa/Windhoek">Africa/Windhoek</option>
<option value="America/Adak">America/Adak</option>
<option value="America/Anchorage">America/Anchorage</option>
<option value="America/Anguilla">America/Anguilla</option>
<option value="America/Antigua">America/Antigua</option>
<option value="America/Araguaina">America/Araguaina</option>
<option value="America/Argentina/Buenos_Aires">America/Argentina/Buenos_Aires</option>
<option value="America/Argentina/Catamarca">America/Argentina/Catamarca</option>
<option value="America/Argentina/Cordoba">America/Argentina/Cordoba</option>
<option value="America/Argentina/Jujuy">America/Argentina/Jujuy</option>
<option value="America/Argentina/La_Rioja">America/Argentina/La_Rioja</option>
<option value="America/Argentina/Mendoza">America/Argentina/Mendoza</option>
<option value="America/Argentina/Rio_Gallegos">America/Argentina/Rio_Gallegos</option>
<option value="America/Argentina/Salta">America/Argentina/Salta</option>
<option value="America/Argentina/San_Juan">America/Argentina/San_Juan</option>
<option value="America/Argentina/San_Luis">America/Argentina/San_Luis</option>
<option value="America/Argentina/Tucuman">America/Argentina/Tucuman</option>
<option value="America/Argentina/Ushuaia">America/Argentina/Ushuaia</option>
<option value="America/Aruba">America/Aruba</option>
<option value="America/Asuncion">America/Asuncion</option>
<option value="America/Atikokan">America/Atikokan</option>
<option value="America/Bahia">America/Bahia</option>
<option value="America/Bahia_Banderas">America/Bahia_Banderas</option>
<option value="America/Barbados">America/Barbados</option>
<option value="America/Belem">America/Belem</option>
<option value="America/Belize">America/Belize</option>
<option value="America/Blanc-Sablon">America/Blanc-Sablon</option>
<option value="America/Boa_Vista">America/Boa_Vista</option>
<option value="America/Bogota">America/Bogota</option>
<option value="America/Boise">America/Boise</option>
<option value="America/Cambridge_Bay">America/Cambridge_Bay</option>
<option value="America/Campo_Grande">America/Campo_Grande</option>
<option value="America/Cancun">America/Cancun</option>
<option value="America/Caracas">America/Caracas</option>
<option value="America/Cayenne">America/Cayenne</option>
<option value="America/Cayman">America/Cayman</option>
<option value="America/Chicago">America/Chicago</option>
<option value="America/Chihuahua">America/Chihuahua</option>
<option value="America/Ciudad_Juarez">America/Ciudad_Juarez</option>
<option value="America/Costa_Rica">America/Costa_Rica</option>
<option value="America/Creston">America/Creston</option>
<option value="America/Cuiaba">America/Cuiaba</option>
<option value="America/Curacao">America/Curacao</option>
<option value="America/Danmarkshavn">America/Danmarkshavn</option>
<option value="America/Dawson">America/Dawson</option>
<option value="America/Dawson_Creek">America/Dawson_Creek</option>
<option value="America/Denver">America/Denver</option>
<option value="America/Detroit">America/Detroit</option>
<option value="America/Dominica">America/Dominica</option>
<option value="America/Edmonton">America/Edmonton</option>
<option value="America/Eirunepe">America/Eirunepe</option>
<option value="America/El_Salvador">America/El_Salvador</option>
<option value="America/Fort_Nelson">America/Fort_Nelson</option>
<option value="America/Fortaleza">America/Fortaleza</option>
<option value="America/Glace_Bay">America/Glace_Bay</option>
<option value="America/Goose_Bay">America/Goose_Bay</option>
<option value="America/Grand_Turk">America/Grand_Turk</option>
<option value="America/Grenada">America/Grenada</option>
<option value="America/Guadeloupe">America/Guadeloupe</option>
<option value="America/Guatemala">America/Guatemala</option>
<option value="America/Guayaquil">America/Guayaquil</option>
<option value="America/Guyana">America/Guyana</option>
<option value="America/Halifax">America/Halifax</option>
<option value="America/Havana">America/Havana</option>
<option value="America/Hermosillo">America/Hermosillo</option>
<option value="America/Indiana/Indianapolis">America/Indiana/Indianapolis</option>
<option value="America/Indiana/Knox">America/Indiana/Knox</option>
<option value="America/Indiana/Marengo">America/Indiana/Marengo</option>
<option value="America/Indiana/Petersburg">America/Indiana/Petersburg</option>
<option value="America/Indiana/Tell_City">America/Indiana/Tell_City</option>
<option value="America/Indiana/Vevay">America/Indiana/Vevay</option>
<option value="America/Indiana/Vincennes">America/Indiana/Vincennes</option>
<option value="America/Indiana/Winamac">America/Indiana/Winamac</option>
<option value="America/Inuvik">America/Inuvik</option>
<option value="America/Iqaluit">America/Iqaluit</option>
<option value="America/Jamaica">America/Jamaica</option>
<option value="America/Juneau">America/Juneau</option>
<option value="America/Kentucky/Louisville">America/Kentucky/Louisville</option>
<option value="America/Kentucky/Monticello">America/Kentucky/Monticello</option>
<option value="America/Kralendijk">America/Kralendijk</option>
<option value="America/La_Paz">America/La_Paz</option>
<option value="America/Lima">America/Lima</option>
<option value="America/Los_Angeles">America/Los_Angeles</option>
<option value="America/Lower_Princes">America/Lower_Princes</option>
<option value="America/Maceio">America/Maceio</option>
<option value="America/Managua">America/Managua</option>
<option value="America/Manaus">America/Manaus</option>
<option value="America/Marigot">America/Marigot</option>
<option value="America/Martinique">America/Martinique</option>
<option value="America/Matamoros">America/Matamoros</option>
<option value="America/Mazatlan">America/Mazatlan</option>
<option value="America/Menominee">America/Menominee</option>
<option value="America/Merida">America/Merida</option>
<option value="America/Metlakatla">America/Metlakatla</option>
<option value="America/Mexico_City">America/Mexico_City</option>
<option value="America/Miquelon">America/Miquelon</option>
<option value="America/Moncton">America/Moncton</option>
<option value="America/Monterrey">America/Monterrey</option>
<option value="America/Montevideo">America/Montevideo</option>
<option value="America/Montserrat">America/Montserrat</option>
<option value="America/Nassau">America/Nassau</option>
<option value="America/New_York">America/New_York</option>
<option value="America/Nome">America/Nome</option>
<option value="America/Noronha">America/Noronha</option>
<option value="America/North_Dakota/Beulah">America/North_Dakota/Beulah</option>
<option value="America/North_Dakota/Center">America/North_Dakota/Center</option>
<option value="America/North_Dakota/New_Salem">America/North_Dakota/New_Salem</option>
<option value="America/Nuuk">America/Nuuk</option>
<option value="America/Ojinaga">America/Ojinaga</option>
<option value="America/Panama">America/Panama</option>
<option value="America/Paramaribo">America/Paramaribo</option>
<option value="America/Phoenix">America/Phoenix</option>
<option value="America/Port-au-Prince">America/Port-au-Prince</option>
<option value="America/Port_of_Spain">America/Port_of_Spain</option>
<option value="America/Porto_Velho">America/Porto_Velho</option>
<option value="America/Puerto_Rico">America/Puerto_Rico</option>
<option value="America/Punta_Arenas">America/Punta_Arenas</option>
<option value="America/Rankin_Inlet">America/Rankin_Inlet</option>
<option value="America/Recife">America/Recife</option>
<option value="America/Regina">America/Regina</option>
<option value="America/Resolute">America/Resolute</option>
<option value="America/Rio_Branco">America/Rio_Branco</option>
<option value="America/Santarem">America/Santarem</option>
<option value="America/Santiago">America/Santiago</option>
<option value="America/Santo_Domingo">America/Santo_Domingo</option>
<option value="America/Sao_Paulo">America/Sao_Paulo</option>
<option value="America/Scoresbysund">America/Scoresbysund</option>
<option value="America/Sitka">America/Sitka</option>
<option value="America/St_Barthelemy">America/St_Barthelemy</option>
<option value="America/St_Johns">America/St_Johns</option>
<option value="America/St_Kitts">America/St_Kitts</option>
<option value="America/St_Lucia">America/St_Lucia</option>
<option value="America/St_Thomas">America/St_Thomas</option>
<option value="America/St_Vincent">America/St_Vincent</option>
<option value="America/Swift_Current">America/Swift_Current</option>
<option value="America/Tegucigalpa">America/Tegucigalpa</option>
<option value="America/Thule">America/Thule</option>
<option value="America/Tijuana">America/Tijuana</option>
<option value="America/Toronto">America/Toronto</option>
<option value="America/Tortola">America/Tortola</option>
<option value="America/Vancouver">America/Vancouver</option>
<option value="America/Whitehorse">America/Whitehorse</option>
<option value="America/Winnipeg">America/Winnipeg</option>
<option value="America/Yakutat">America/Yakutat</option>
<option value="Antarctica/Casey">Antarctica/Casey</option>
<option value="Antarctica/Davis">Antarctica/Davis</option>
<option value="Antarctica/DumontDUrville">Antarctica/DumontDUrville</option>
<option value="Antarctica/Macquarie">Antarctica/Macquarie</option>
<option value="Antarctica/Mawson">Antarctica/Mawson</option>
<option value="Antarctica/McMurdo">Antarctica/McMurdo</option>
<option value="Antarctica/Palmer">Antarctica/Palmer</option>
<option value="Antarctica/Rothera">Antarctica/Rothera</option>
<option value="Antarctica/Syowa">Antarctica/Syowa</option>
<option value="Antarctica/Troll">Antarctica/Troll</option>
<option value="Antarctica/Vostok">Antarctica/Vostok</option>
<option value="Arctic/Longyearbyen">Arctic/Longyearbyen</option>
<option value="Asia/Aden">Asia/Aden</option>
<option value="Asia/Almaty">Asia/Almaty</option>
<option value="Asia/Amman">Asia/Amman</option>
<option value="Asia/Anadyr">Asia/Anadyr</option>
<option value="Asia/Aqtau">Asia/Aqtau</option>
<option value="Asia/Aqtobe">Asia/Aqtobe</option>
<option value="Asia/Ashgabat">Asia/Ashgabat</option>
<option value="Asia/Atyrau">Asia/Atyrau</option>
<option value="Asia/Baghdad">Asia/Baghdad</option>
<option value="Asia/Bahrain">Asia/Bahrain</option>
<option value="Asia/Baku">Asia/Baku</option>
<option value="Asia/Bangkok">Asia/Bangkok</option>
<option value="Asia/Barnaul">Asia/Barnaul</option>
<option value="Asia/Beirut">Asia/Beirut</option>
<option value="Asia/Bishkek">Asia/Bishkek</option>
<option value="Asia/Brunei">Asia/Brunei</option>
<option value="Asia/Chita">Asia/Chita</option>
<option value="Asia/Colombo" selected="selected">Asia/Colombo</option>
<option value="Asia/Damascus">Asia/Damascus</option>
<option value="Asia/Dhaka">Asia/Dhaka</option>
<option value="Asia/Dili">Asia/Dili</option>
<option value="Asia/Dubai">Asia/Dubai</option>
<option value="Asia/Dushanbe">Asia/Dushanbe</option>
<option value="Asia/Famagusta">Asia/Famagusta</option>
<option value="Asia/Gaza">Asia/Gaza</option>
<option value="Asia/Hebron">Asia/Hebron</option>
<option value="Asia/Ho_Chi_Minh">Asia/Ho_Chi_Minh</option>
<option value="Asia/Hong_Kong">Asia/Hong_Kong</option>
<option value="Asia/Hovd">Asia/Hovd</option>
<option value="Asia/Irkutsk">Asia/Irkutsk</option>
<option value="Asia/Jakarta">Asia/Jakarta</option>
<option value="Asia/Jayapura">Asia/Jayapura</option>
<option value="Asia/Jerusalem">Asia/Jerusalem</option>
<option value="Asia/Kabul">Asia/Kabul</option>
<option value="Asia/Kamchatka">Asia/Kamchatka</option>
<option value="Asia/Karachi">Asia/Karachi</option>
<option value="Asia/Kathmandu">Asia/Kathmandu</option>
<option value="Asia/Khandyga">Asia/Khandyga</option>
<option value="Asia/Kolkata">Asia/Kolkata</option>
<option value="Asia/Krasnoyarsk">Asia/Krasnoyarsk</option>
<option value="Asia/Kuala_Lumpur">Asia/Kuala_Lumpur</option>
<option value="Asia/Kuching">Asia/Kuching</option>
<option value="Asia/Kuwait">Asia/Kuwait</option>
<option value="Asia/Macau">Asia/Macau</option>
<option value="Asia/Magadan">Asia/Magadan</option>
<option value="Asia/Makassar">Asia/Makassar</option>
<option value="Asia/Manila">Asia/Manila</option>
<option value="Asia/Muscat">Asia/Muscat</option>
<option value="Asia/Nicosia">Asia/Nicosia</option>
<option value="Asia/Novokuznetsk">Asia/Novokuznetsk</option>
<option value="Asia/Novosibirsk">Asia/Novosibirsk</option>
<option value="Asia/Omsk">Asia/Omsk</option>
<option value="Asia/Oral">Asia/Oral</option>
<option value="Asia/Phnom_Penh">Asia/Phnom_Penh</option>
<option value="Asia/Pontianak">Asia/Pontianak</option>
<option value="Asia/Pyongyang">Asia/Pyongyang</option>
<option value="Asia/Qatar">Asia/Qatar</option>
<option value="Asia/Qostanay">Asia/Qostanay</option>
<option value="Asia/Qyzylorda">Asia/Qyzylorda</option>
<option value="Asia/Riyadh">Asia/Riyadh</option>
<option value="Asia/Sakhalin">Asia/Sakhalin</option>
<option value="Asia/Samarkand">Asia/Samarkand</option>
<option value="Asia/Seoul">Asia/Seoul</option>
<option value="Asia/Shanghai">Asia/Shanghai</option>
<option value="Asia/Singapore">Asia/Singapore</option>
<option value="Asia/Srednekolymsk">Asia/Srednekolymsk</option>
<option value="Asia/Taipei">Asia/Taipei</option>
<option value="Asia/Tashkent">Asia/Tashkent</option>
<option value="Asia/Tbilisi">Asia/Tbilisi</option>
<option value="Asia/Tehran">Asia/Tehran</option>
<option value="Asia/Thimphu">Asia/Thimphu</option>
<option value="Asia/Tokyo">Asia/Tokyo</option>
<option value="Asia/Tomsk">Asia/Tomsk</option>
<option value="Asia/Ulaanbaatar">Asia/Ulaanbaatar</option>
<option value="Asia/Urumqi">Asia/Urumqi</option>
<option value="Asia/Ust-Nera">Asia/Ust-Nera</option>
<option value="Asia/Vientiane">Asia/Vientiane</option>
<option value="Asia/Vladivostok">Asia/Vladivostok</option>
<option value="Asia/Yakutsk">Asia/Yakutsk</option>
<option value="Asia/Yangon">Asia/Yangon</option>
<option value="Asia/Yekaterinburg">Asia/Yekaterinburg</option>
<option value="Asia/Yerevan">Asia/Yerevan</option>
<option value="Atlantic/Azores">Atlantic/Azores</option>
<option value="Atlantic/Bermuda">Atlantic/Bermuda</option>
<option value="Atlantic/Canary">Atlantic/Canary</option>
<option value="Atlantic/Cape_Verde">Atlantic/Cape_Verde</option>
<option value="Atlantic/Faroe">Atlantic/Faroe</option>
<option value="Atlantic/Madeira">Atlantic/Madeira</option>
<option value="Atlantic/Reykjavik">Atlantic/Reykjavik</option>
<option value="Atlantic/South_Georgia">Atlantic/South_Georgia</option>
<option value="Atlantic/St_Helena">Atlantic/St_Helena</option>
<option value="Atlantic/Stanley">Atlantic/Stanley</option>
<option value="Australia/Adelaide">Australia/Adelaide</option>
<option value="Australia/Brisbane">Australia/Brisbane</option>
<option value="Australia/Broken_Hill">Australia/Broken_Hill</option>
<option value="Australia/Darwin">Australia/Darwin</option>
<option value="Australia/Eucla">Australia/Eucla</option>
<option value="Australia/Hobart">Australia/Hobart</option>
<option value="Australia/Lindeman">Australia/Lindeman</option>
<option value="Australia/Lord_Howe">Australia/Lord_Howe</option>
<option value="Australia/Melbourne">Australia/Melbourne</option>
<option value="Australia/Perth">Australia/Perth</option>
<option value="Australia/Sydney">Australia/Sydney</option>
<option value="Europe/Amsterdam">Europe/Amsterdam</option>
<option value="Europe/Andorra">Europe/Andorra</option>
<option value="Europe/Astrakhan">Europe/Astrakhan</option>
<option value="Europe/Athens">Europe/Athens</option>
<option value="Europe/Belgrade">Europe/Belgrade</option>
<option value="Europe/Berlin">Europe/Berlin</option>
<option value="Europe/Bratislava">Europe/Bratislava</option>
<option value="Europe/Brussels">Europe/Brussels</option>
<option value="Europe/Bucharest">Europe/Bucharest</option>
<option value="Europe/Budapest">Europe/Budapest</option>
<option value="Europe/Busingen">Europe/Busingen</option>
<option value="Europe/Chisinau">Europe/Chisinau</option>
<option value="Europe/Copenhagen">Europe/Copenhagen</option>
<option value="Europe/Dublin">Europe/Dublin</option>
<option value="Europe/Gibraltar">Europe/Gibraltar</option>
<option value="Europe/Guernsey">Europe/Guernsey</option>
<option value="Europe/Helsinki">Europe/Helsinki</option>
<option value="Europe/Isle_of_Man">Europe/Isle_of_Man</option>
<option value="Europe/Istanbul">Europe/Istanbul</option>
<option value="Europe/Jersey">Europe/Jersey</option>
<option value="Europe/Kaliningrad">Europe/Kaliningrad</option>
<option value="Europe/Kirov">Europe/Kirov</option>
<option value="Europe/Kyiv">Europe/Kyiv</option>
<option value="Europe/Lisbon">Europe/Lisbon</option>
<option value="Europe/Ljubljana">Europe/Ljubljana</option>
<option value="Europe/London">Europe/London</option>
<option value="Europe/Luxembourg">Europe/Luxembourg</option>
<option value="Europe/Madrid">Europe/Madrid</option>
<option value="Europe/Malta">Europe/Malta</option>
<option value="Europe/Mariehamn">Europe/Mariehamn</option>
<option value="Europe/Minsk">Europe/Minsk</option>
<option value="Europe/Monaco">Europe/Monaco</option>
<option value="Europe/Moscow">Europe/Moscow</option>
<option value="Europe/Oslo">Europe/Oslo</option>
<option value="Europe/Paris">Europe/Paris</option>
<option value="Europe/Podgorica">Europe/Podgorica</option>
<option value="Europe/Prague">Europe/Prague</option>
<option value="Europe/Riga">Europe/Riga</option>
<option value="Europe/Rome">Europe/Rome</option>
<option value="Europe/Samara">Europe/Samara</option>
<option value="Europe/San_Marino">Europe/San_Marino</option>
<option value="Europe/Sarajevo">Europe/Sarajevo</option>
<option value="Europe/Saratov">Europe/Saratov</option>
<option value="Europe/Simferopol">Europe/Simferopol</option>
<option value="Europe/Skopje">Europe/Skopje</option>
<option value="Europe/Sofia">Europe/Sofia</option>
<option value="Europe/Stockholm">Europe/Stockholm</option>
<option value="Europe/Tallinn">Europe/Tallinn</option>
<option value="Europe/Tirane">Europe/Tirane</option>
<option value="Europe/Ulyanovsk">Europe/Ulyanovsk</option>
<option value="Europe/Vaduz">Europe/Vaduz</option>
<option value="Europe/Vatican">Europe/Vatican</option>
<option value="Europe/Vienna">Europe/Vienna</option>
<option value="Europe/Vilnius">Europe/Vilnius</option>
<option value="Europe/Volgograd">Europe/Volgograd</option>
<option value="Europe/Warsaw">Europe/Warsaw</option>
<option value="Europe/Zagreb">Europe/Zagreb</option>
<option value="Europe/Zurich">Europe/Zurich</option>
<option value="Indian/Antananarivo">Indian/Antananarivo</option>
<option value="Indian/Chagos">Indian/Chagos</option>
<option value="Indian/Christmas">Indian/Christmas</option>
<option value="Indian/Cocos">Indian/Cocos</option>
<option value="Indian/Comoro">Indian/Comoro</option>
<option value="Indian/Kerguelen">Indian/Kerguelen</option>
<option value="Indian/Mahe">Indian/Mahe</option>
<option value="Indian/Maldives">Indian/Maldives</option>
<option value="Indian/Mauritius">Indian/Mauritius</option>
<option value="Indian/Mayotte">Indian/Mayotte</option>
<option value="Indian/Reunion">Indian/Reunion</option>
<option value="Pacific/Apia">Pacific/Apia</option>
<option value="Pacific/Auckland">Pacific/Auckland</option>
<option value="Pacific/Bougainville">Pacific/Bougainville</option>
<option value="Pacific/Chatham">Pacific/Chatham</option>
<option value="Pacific/Chuuk">Pacific/Chuuk</option>
<option value="Pacific/Easter">Pacific/Easter</option>
<option value="Pacific/Efate">Pacific/Efate</option>
<option value="Pacific/Fakaofo">Pacific/Fakaofo</option>
<option value="Pacific/Fiji">Pacific/Fiji</option>
<option value="Pacific/Funafuti">Pacific/Funafuti</option>
<option value="Pacific/Galapagos">Pacific/Galapagos</option>
<option value="Pacific/Gambier">Pacific/Gambier</option>
<option value="Pacific/Guadalcanal">Pacific/Guadalcanal</option>
<option value="Pacific/Guam">Pacific/Guam</option>
<option value="Pacific/Honolulu">Pacific/Honolulu</option>
<option value="Pacific/Kanton">Pacific/Kanton</option>
<option value="Pacific/Kiritimati">Pacific/Kiritimati</option>
<option value="Pacific/Kosrae">Pacific/Kosrae</option>
<option value="Pacific/Kwajalein">Pacific/Kwajalein</option>
<option value="Pacific/Majuro">Pacific/Majuro</option>
<option value="Pacific/Marquesas">Pacific/Marquesas</option>
<option value="Pacific/Midway">Pacific/Midway</option>
<option value="Pacific/Nauru">Pacific/Nauru</option>
<option value="Pacific/Niue">Pacific/Niue</option>
<option value="Pacific/Norfolk">Pacific/Norfolk</option>
<option value="Pacific/Noumea">Pacific/Noumea</option>
<option value="Pacific/Pago_Pago">Pacific/Pago_Pago</option>
<option value="Pacific/Palau">Pacific/Palau</option>
<option value="Pacific/Pitcairn">Pacific/Pitcairn</option>
<option value="Pacific/Pohnpei">Pacific/Pohnpei</option>
<option value="Pacific/Port_Moresby">Pacific/Port_Moresby</option>
<option value="Pacific/Rarotonga">Pacific/Rarotonga</option>
<option value="Pacific/Saipan">Pacific/Saipan</option>
<option value="Pacific/Tahiti">Pacific/Tahiti</option>
<option value="Pacific/Tarawa">Pacific/Tarawa</option>
<option value="Pacific/Tongatapu">Pacific/Tongatapu</option>
<option value="Pacific/Wake">Pacific/Wake</option>
<option value="Pacific/Wallis">Pacific/Wallis</option>
<option value="UTC">UTC</option>
</select>
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group" style="margin-top: 32px;">
<label class="label_register" for="show_for_customers">
<input class="" id="show_for_customers" name="show_for_customers" type="checkbox" value="1"> Need to Show for the customer</label>
</div>
</div>
<div class="col-sm-4 business_categories_div hide">
<div class="form-group">
<label for="business_categories" class="label_register">Business Categories:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-bars"></i>
</span>
<select class="form-control select2
business_categories" id="business_categories" multiple="" style="width: 100%;
margin:0px;" name="business_categories[]"></select>
</div>
</div>
</div>
</div>
</fieldset>
<!-- tax details -->
<h3>Business Settings</h3>
<fieldset>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="tax_label_1" class="label_register">Tax 1 Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="GST / VAT / Other" name="tax_label_1" type="text" id="tax_label_1">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="tax_number_1" class="label_register">Tax 1 No.:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" name="tax_number_1" type="text" id="tax_number_1">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-sm-4">
<div class="form-group">
<label for="tax_label_2" class="label_register">Tax 2 Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="GST / VAT / Other" name="tax_label_2" type="text" id="tax_label_2">
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="tax_number_2" class="label_register">Tax 2 No.:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" name="tax_number_2" type="text" id="tax_number_2">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-sm-4">
<div class="form-group">
<label for="fy_start_month" class="label_register">Financial year start month:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-calendar"></i>
</span>
<select class="form-control select2" required="" style="width:100%; margin: 0px;" id="fy_start_month" name="fy_start_month"></select>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="form-group">
<label for="accounting_method" class="label_register">Stock Accounting Method:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-calculator"></i>
</span>
<select class="form-control
select2" required="" style="width:100%; margin:0px;" id="accounting_method" name="accounting_method">
<option value="fifo">FIFO (First In First Out)</option>
<option value="lifo">LIFO (Last In First Out)</option>
</select>
</div>
</div>
</div>
</div>
</fieldset>
<!-- Owner Information -->
<h3>Owner</h3>
<fieldset>
<legend>Owner information</legend>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="surname" class="label_register">Prefix:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="Mr / Mrs / Miss" id="b_surname" name="surname" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="b_first_name" class="label_register">First Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="First Name" required="" id="b_first_name" autocomplete="on" name="first_name" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="b_last_name" class="label_register">Last Name:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-info"></i>
</span>
<input class="form-control" placeholder="Last Name" id="b_last_name" name="last_name" type="text">
</div>
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="b_username" class="label_register">Username:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Username" id="b_username" required="" autocomplete="on" name="username" type="text">
</div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<label for="b_email" class="label_register">Email:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-envelope"></i>
</span>
<input class="form-control" placeholder="Email" id="b_email" autocomplete="on" name="email" type="text">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-sm-4">
<div class="form-group">
<label for="b_password" class="label_register">Password:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-lock"></i>
</span>
<input class="form-control" placeholder="Password" id="b_password" style="margin:0px;" required="" name="password" type="password" value="">
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4">
<div class="form-group">
<label for="b_confirm_password" class="label_register">Confirm Password:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-lock"></i>
</span>
<input class="form-control" placeholder="Confirm Password" style="margin:0px;" required="" id="b_confirm_password" name="confirm_password" type="password" value="">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-sm-4">
</div>
<div class="clearfix"></div>
</div>
<div class="col-md-12">
<div class="form-group" style="padding:auto; margin-top:10px;margin-bottom:10px;">
<div class="g-recaptcha" data-sitekey="6Le0JCsdAAAAAMz-cD3AL5Xh-SOCUCaXIP8dbZmi"></div>
</div>
</div>
</fieldset>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row">
<div class="col-sm-4" style="text-align: left;">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
<div class="col-sm-4" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Submit</button>
</div>
</div>
</div> <input name="package_id" type="hidden" value="0">
</form>POST https://cool10.vimi50.site/register/customer
<form method="POST" action="https://cool10.vimi50.site/register/customer" accept-charset="UTF-8" id="customer_register_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<style>
</style>
<fieldset>
<div id="patient_register" style="border-radius: 5px; ">
<style>
label {
color: black;
font-weight: 800;
}
</style>
<div class="modal-body">
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="c_first_name">First Name:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="First Name" id="c_first_name" required="" autocomplete="on" name="first_name" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="c_last_name">Last Name:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Last Name" id="c_last_name" required="" name="last_name" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="c_username">Username:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Username" id="c_username" required="" autocomplete="on" name="username" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="c_email">Email:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-envelope"></i>
</span>
<input class="form-control" placeholder="Email" id="c_email" autocomplete="on" name="email" type="email">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="c_password">Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>
</span>
<input class="form-control" id="c_password" style="margin: 0px;" placeholder="Password" name="password" type="password" value="">
</div>
<p class="help-block" style="color: white;">At least 6 character.</p>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="c_confirm_password">Confirm Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>, </span>
<input class="form-control" id="c_confirm_password" style="margin: 0px;" placeholder="Confirm Password" name="confirm_password" type="password" value="">
</div>
</div>
</div>
<div class="col-md-12">
<hr>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="c_mobile">Mobile:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-mobile"></i>
</span>
<input class="form-control" required="" placeholder="Mobile" id="c_mobile" name="mobile" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="customer_alternate_number">Alternate contact number:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Alternate contact number" alternate_number="customer_alternate_number" id="customer_alternate_number" name="contact_number" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="landline">Landline:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Landline" name="landline" type="text" id="landline">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-4">
<div class="form-group">
<label for="geo_location">Geo Location:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="contact.geo_location" name="geo_location" type="text" id="geo_location">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="customer_address">Address:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" required="" placeholder="Address" id="customer_address" autocomplete="on" name="address" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="town">Town:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" required="" placeholder="Town" name="town" type="text" id="town">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-4">
<div class="form-group">
<label for="district">District:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" required="" placeholder="District" name="district" type="text" id="district">
</div>
</div>
</div>
<div class="col-md-12">
<div class="form-group" style="padding:auto; margin-top:10px;margin-bottom:10px;">
<div class="g-recaptcha" data-sitekey="6Le0JCsdAAAAAMz-cD3AL5Xh-SOCUCaXIP8dbZmi"></div>
</div>
</div>
</div>
<div class="clearfix"></div>
</div>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row">
<div class="col-md-6" style="text-align: left;">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
<div class="col-md-6" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Submit</button>
</div>
</div>
</div>
</div>
</fieldset> <input name="package_id" type="hidden" value="0">
</form>POST https://cool10.vimi50.site/register/member
<form method="POST" action="https://cool10.vimi50.site/register/member" accept-charset="UTF-8" id="member_register_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<style>
#patient_register {
background: {
{
$login_background_color
}
}
!important;
}
label {
color: white !important;
}
</style>
<fieldset>
<div id="patient_register" style="border-radius: 5px;">
<style>
label {
color: black;
font-weight: 800;
}
</style>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="username">Member Code:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Member Code" required="" readonly="" autocomplete="on" name="username" type="text" value="MEM5" id="username">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_name">Name:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Name" required="" name="member_name" type="text" id="member_name">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_address">Address:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Address" required="" autocomplete="on" name="member_address" type="text" id="member_address">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_town">Town:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Town" required="" name="member_town" type="text" id="member_town">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_district">District:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="District" required="" name="member_district" type="text" id="member_district">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_mobile_number_1">Mobile Number 1:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Mobile Number 1" required="" name="member_mobile_number_1" type="text" id="member_mobile_number_1">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_mobile_number_2">Mobile Number 2:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Mobile Number 2" name="member_mobile_number_2" type="text" id="member_mobile_number_2">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_mobile_number_3">Mobile Number 3:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Mobile Number 3" name="member_mobile_number_3" type="text" id="member_mobile_number_3">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_land_number">Land Number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Land Number" name="member_land_number" type="text" id="member_land_number">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_gender">Gender:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<select class="form-control" style="margin:0px" required="" id="member_gender" name="member_gender">
<option selected="selected" value="">Please Select</option>
<option value="male">Male</option>
<option value="female">Female</option>
</select>
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="date_of_birth">Date of Birth:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<input class="form-control" placeholder="Date of Birth" id="date_of_birth" name="member_date_of_birth" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="gramasevaka_area">Gramasevaka Area:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<select class="form-control" style="margin:0px" id="gramasevaka_area" name="gramasevaka_area">
<option selected="selected" value="">Please Select</option>
</select>
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="bala_mandalaya_area">Bala Mandalaya Area:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<select class="form-control" style="margin:0px" id="bala_mandalaya_area" name="bala_mandalaya_area">
<option selected="selected" value="">Please Select</option>
</select>
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_group">Member Group:*</label>
<div class="input-group">
<span class="input-group-addon">
<i></i>
</span>
<select class="form-control" style="margin:0px" required="" id="member_group" name="member_group">
<option selected="selected" value="">Please Select</option>
</select>
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_password">Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>
</span>
<input class="form-control" id="member_password" style="margin: 0px;" placeholder="Password" name="member_password" type="password" value="">
</div>
<p class="help-block" style="color: white;">At least 6 character.</p>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="member_confirm_password">Confirm Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>, </span>
<input class="form-control" id="member_confirm_password" style="margin: 0px;" placeholder="Confirm Password" name="member_confirm_password" type="password" value="">
</div>
</div>
</div>
<div class="col-md-12">
<div class="form-group" style="padding:auto; margin-top:10px;margin-bottom:10px;">
<div class="g-recaptcha" data-sitekey="6Le0JCsdAAAAAMz-cD3AL5Xh-SOCUCaXIP8dbZmi"></div>
</div>
</div>
</div>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row">
<div class="col-md-6" style="text-align: left;">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
<div class="col-md-6" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Submit</button>
</div>
</div>
</div>
</div>
</fieldset>
</form>POST https://cool10.vimi50.site/business/patient-register
<form method="POST" action="https://cool10.vimi50.site/business/patient-register" accept-charset="UTF-8" id="patient_register_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<style>
/*#patient_register {*/
/* background: {*/
/* {*/
/* $login_background_color*/
/* }*/
/* }*/
/* !important;*/
/*}*/
label {
color: #000000 !important;
}
.file-preview-frame {
margin: 0 !important;
}
</style>
<fieldset>
<div id="patient_register" style="border-radius: 5px;">
<style>
label {
color: black;
font-weight: 800;
}
</style>
<div class="modal-body body2">
<input class="package_id" name="package_id" type="hidden">
<div class="row">
<div class="col-md-4">
<div class="form-group">
<small>First Name:*</small>
<input type="text" name="join_date" id="join_date" value="2024-11-10" class="form-control" readonly="readonly" required="" placeholder="Date">
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>First Name:*</small>
<input type="text" name="first_name" id="p_first_name" class="form-control" required="" placeholder="First Name" autocomplete="on">
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Last Name:*</small>
<input type="text" name="last_name" id="p_last_name" class="form-control" required="" placeholder="Last Name">
</div>
</div>
</div>
<!--
<div class="row d-none">
<div class="col-md-4">
<div class="form-group">
<small>Address:*</small>
<input type="text" name="address" id="p_address" class="form-control" required placeholder="Address" autocomplete="on" />
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>City:*</small>
<input type="text" name="city" id="p_city" class="form-control" required placeholder="City" />
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>State :*</small>
<input type="text" name="state" id="p_state" class="form-control" required placeholder="State" />
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>District :*</small>
<input type="text" name="district" id="p_district" class="form-control" required placeholder="District" />
</div>
</div>
</div>
-->
<div class="row">
<!--
<input type="hidden" name="country" id="p_country" class="form-control" required placeholder="country" />
-->
<div class="col-md-4">
<div class="form-group">
<small>Mobile Phone:*</small>
<input type="text" name="mobile" id="p_mobile" class="form-control" required="" placeholder="Mobile">
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Date of Birth:*</small>
<input type="date" name="date_of_birth" id="p_date_of_birth" class="form-control" required="" placeholder="Date of birth">
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<small>Email:</small>
<input type="email" name="p_email" id="p_email" class="form-control" placeholder="Email" autocomplete="on">
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Password:*</small>
<input type="password" name="p_password" id="p_password" class="form-control" required="" placeholder="Password">
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Reenter Password:*</small>
<input type="password" name="p_confirm_password" id="p_confirm_password" class="form-control" placeholder="Confrim Password" required="">
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<small>Gender:*</small>
<select name="gender" id="p_gender" class="form-control select2" required="">
<option value="">Select Gender</option>
<option value="1">Male</option>
<option value="2">Female</option>
</select>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Marital status:*</small>
<select name="marital_status" id="marital_status" class="form-control select2" required="">
<option value="">Select Marital status</option>
<option value="1">Married</option>
<option value="2">UnMarried</option>
</select>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Blood Group</small>
<select name="blood_group" id="blood_group" class="form-control select2">
<option value="">Select Blood Group</option>
<option value="1">AB-</option>
<option value="2">A-</option>
<option value="3">B-</option>
<option value="4">O-</option>
<option value="5">AB+</option>
<option value="6">A+</option>
<option value="7">B+</option>
<option value="8">O+</option>
<option value="9">Not Known</option>
</select>
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<small>Time / Zone</small>
<select name="time_zone" class="form-control select2">
<option>Time / Zone</option>
<option value="Etc/GMT+12">(GMT-12:00) International Date Line West</option>
<option value="Pacific/Midway">(GMT-11:00) Midway Island, Samoa</option>
<option value="Pacific/Honolulu">(GMT-10:00) Hawaii</option>
<option value="US/Alaska">(GMT-09:00) Alaska</option>
<option value="America/Los_Angeles">(GMT-08:00) Pacific Time (US & Canada)</option>
<option value="America/Tijuana">(GMT-08:00) Tijuana, Baja California</option>
<option value="US/Arizona">(GMT-07:00) Arizona</option>
<option value="America/Chihuahua">(GMT-07:00) Chihuahua, La Paz, Mazatlan</option>
<option value="US/Mountain">(GMT-07:00) Mountain Time (US & Canada)</option>
<option value="America/Managua">(GMT-06:00) Central America</option>
<option value="US/Central">(GMT-06:00) Central Time (US & Canada)</option>
<option value="America/Mexico_City">(GMT-06:00) Guadalajara, Mexico City, Monterrey</option>
<option value="Canada/Saskatchewan">(GMT-06:00) Saskatchewan</option>
<option value="America/Bogota">(GMT-05:00) Bogota, Lima, Quito, Rio Branco</option>
<option value="US/Eastern">(GMT-05:00) Eastern Time (US & Canada)</option>
<option value="US/East-Indiana">(GMT-05:00) Indiana (East)</option>
<option value="Canada/Atlantic">(GMT-04:00) Atlantic Time (Canada)</option>
<option value="America/Caracas">(GMT-04:00) Caracas, La Paz</option>
<option value="America/Manaus">(GMT-04:00) Manaus</option>
<option value="America/Santiago">(GMT-04:00) Santiago</option>
<option value="Canada/Newfoundland">(GMT-03:30) Newfoundland</option>
<option value="America/Sao_Paulo">(GMT-03:00) Brasilia</option>
<option value="America/Argentina/Buenos_Aires">(GMT-03:00) Buenos Aires, Georgetown</option>
<option value="America/Godthab">(GMT-03:00) Greenland</option>
<option value="America/Montevideo">(GMT-03:00) Montevideo</option>
<option value="America/Noronha">(GMT-02:00) Mid-Atlantic</option>
<option value="Atlantic/Cape_Verde">(GMT-01:00) Cape Verde Is.</option>
<option value="Atlantic/Azores">(GMT-01:00) Azores</option>
<option value="Africa/Casablanca">(GMT+00:00) Casablanca, Monrovia, Reykjavik</option>
<option value="Etc/Greenwich">(GMT+00:00) Greenwich Mean Time : Dublin, Edinburgh, Lisbon, London</option>
<option value="Europe/Amsterdam">(GMT+01:00) Amsterdam, Berlin, Bern, Rome, Stockholm, Vienna</option>
<option value="Europe/Belgrade">(GMT+01:00) Belgrade, Bratislava, Budapest, Ljubljana, Prague</option>
<option value="Europe/Brussels">(GMT+01:00) Brussels, Copenhagen, Madrid, Paris</option>
<option value="Europe/Sarajevo">(GMT+01:00) Sarajevo, Skopje, Warsaw, Zagreb</option>
<option value="Africa/Lagos">(GMT+01:00) West Central Africa</option>
<option value="Asia/Amman">(GMT+02:00) Amman</option>
<option value="Europe/Athens">(GMT+02:00) Athens, Bucharest, Istanbul</option>
<option value="Asia/Beirut">(GMT+02:00) Beirut</option>
<option value="Africa/Cairo">(GMT+02:00) Cairo</option>
<option value="Africa/Harare">(GMT+02:00) Harare, Pretoria</option>
<option value="Europe/Helsinki">(GMT+02:00) Helsinki, Kyiv, Riga, Sofia, Tallinn, Vilnius </option>
<option value="Asia/Jerusalem">(GMT+02:00) Jerusalem</option>
<option value="Europe/Minsk">(GMT+02:00) Minsk</option>
<option value="Africa/Windhoek">(GMT+02:00) Windhoek</option>
<option value="Asia/Kuwait">(GMT+03:00) Kuwait, Riyadh, Baghdad</option>
<option value="Europe/Moscow">(GMT+03:00) Moscow, St. Petersburg, Volgograd</option>
<option value="Africa/Nairobi">(GMT+03:00) Nairobi</option>
<option value="Asia/Tbilisi">(GMT+03:00) Tbilisi</option>
<option value="Asia/Tehran">(GMT+03:30) Tehran</option>
<option value="Asia/Muscat">(GMT+04:00) Abu Dhabi, Muscat</option>
<option value="Asia/Baku">(GMT+04:00) Baku</option>
<option value="Asia/Yerevan">(GMT+04:00) Yerevan</option>
<option value="Asia/Kabul">(GMT+04:30) Kabul</option>
<option value="Asia/Yekaterinburg">(GMT+05:00) Yekaterinburg</option>
<option value="Asia/Karachi">(GMT+05:00) Islamabad, Karachi, Tashkent</option>
<option value="Asia/Calcutta">(GMT+05:30) Chennai, Kolkata, Mumbai, New Delhi</option>
<option value="Asia/Calcutta">(GMT+05:30) Sri Jayawardenapura</option>
<option value="Asia/Katmandu">(GMT+05:45) Kathmandu</option>
<option value="Asia/Almaty">(GMT+06:00) Almaty, Novosibirsk</option>
<option value="Asia/Dhaka">(GMT+06:00) Astana, Dhaka</option>
<option value="Asia/Rangoon">(GMT+06:30) Yangon (Rangoon)</option>
<option value="Asia/Bangkok">(GMT+07:00) Bangkok, Hanoi, Jakarta</option>
<option value="Asia/Krasnoyarsk">(GMT+07:00) Krasnoyarsk</option>
<option value="Asia/Hong_Kong">(GMT+08:00) Beijing, Chongqing, Hong Kong, Urumqi</option>
<option value="Asia/Kuala_Lumpur">(GMT+08:00) Kuala Lumpur, Singapore</option>
<option value="Asia/Irkutsk">(GMT+08:00) Irkutsk, Ulaan Bataar</option>
<option value="Australia/Perth">(GMT+08:00) Perth</option>
<option value="Asia/Taipei">(GMT+08:00) Taipei</option>
<option value="Asia/Tokyo">(GMT+09:00) Osaka, Sapporo, Tokyo</option>
<option value="Asia/Seoul">(GMT+09:00) Seoul</option>
<option value="Asia/Yakutsk">(GMT+09:00) Yakutsk</option>
<option value="Australia/Adelaide">(GMT+09:30) Adelaide</option>
<option value="Australia/Darwin">(GMT+09:30) Darwin</option>
<option value="Australia/Brisbane">(GMT+10:00) Brisbane</option>
<option value="Australia/Canberra">(GMT+10:00) Canberra, Melbourne, Sydney</option>
<option value="Australia/Hobart">(GMT+10:00) Hobart</option>
<option value="Pacific/Guam">(GMT+10:00) Guam, Port Moresby</option>
<option value="Asia/Vladivostok">(GMT+10:00) Vladivostok</option>
<option value="Asia/Magadan">(GMT+11:00) Magadan, Solomon Is., New Caledonia</option>
<option value="Pacific/Auckland">(GMT+12:00) Auckland, Wellington</option>
<option value="Pacific/Fiji">(GMT+12:00) Fiji, Kamchatka, Marshall Is.</option>
<option value="Pacific/Tongatapu">(GMT+13:00) Nuku'alofa</option>
</select>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<small>Upload Your Image</small>
</div>
<div class="form-group">
<!--
<input type="file" name="fileToImage" id="fileToImage" accept="image/*" onchange="showMyImage(this)" style="border: none;padding: 0px;margin: 0px;">
-->
<input type="file" name="fileToImage" id="fileToImage" accept="image/*" style="border: none;padding: 0px;margin: 0px;">
</div>
</div>
<div class="col-md-4" style="padding-left: 0px;">
<div class="form-group">
<small>Height</small>
<input type="text" name="height" id="height" class="form-control" placeholder="Height">
</div>
</div>
<div class="col-md-4" style="padding-right: 0px;">
<div class="form-group">
<small>Weight</small>
<input type="text" name="weight" id="weight" class="form-control" placeholder="Weight">
</div>
</div>
<div class="form-group col-md-4">
<small>Guardian Name</small>
<input type="text" name="guardian_name" id="guardian_name" class="form-control" placeholder="Guardian Name">
</div>
<div class="form-group col-md-4">
<small>Any Known Allergies</small>
<input type="text" name="known_allergies" id="known_allergies" class="form-control" placeholder="Knwon Allergies">
</div>
<div class="form-group col-md-4">
<label for="referral_code">Referral Code</label> <small>Please enter the Referral code if any</small>
<input class="form-control" placeholder="Referral Code" style="width: 100%;" name="referral_code" type="text" value="0" id="referral_code">
</div>
<div class="col-md-8">
<div class="form-group">
<small>Notes</small>
<textarea name="notes" class="form-control" placeholder="Notes"></textarea>
</div>
<div class="clearfix"></div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="form-group" style="padding:auto; margin-top:10px;margin-bottom:10px;">
<div class="g-recaptcha" data-sitekey="6Le0JCsdAAAAAMz-cD3AL5Xh-SOCUCaXIP8dbZmi"></div>
</div>
</div>
</div>
</div>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row">
<div class="col-md-6" style="text-align: left;">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
<div class="col-md-6" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Submit</button>
</div>
</div>
</div>
</div>
</fieldset>
<script>
/*
// Function to display the location details
function displayLocationDetails(address) {
const state = document.getElementById('p_state');
const address1 = document.getElementById('p_address');
const country = document.getElementById('p_country');
const district = document.getElementById('p_district');
const city = document.getElementById('p_city');
state.value = `${address.state}`;
city.value = `${address.city}`;
country.value = `${address.country}`;
district.value = `${address.district}`;
address1.value = `${address.formatted_address}`;
}
// Function to get address from coordinates using Google Maps API
function getAddressFromCoordinates(latitude, longitude) {
const apiKey = 'AIzaSyCsHrbMB_bsgtLPVdv63bbvLOoszPN4bw8'; // Replace with your API key
const url = `https://maps.googleapis.com/maps/api/geocode/json?latlng=${latitude},${longitude}&key=${apiKey}`;
fetch(url)
.then(response => response.json())
.then(data => {
if (data.status === 'OK' && data.results.length > 0) {
const addressComponents = data.results[0].address_components;
const address = {
formatted_address: data.results[0].formatted_address,
city: '',
district: '',
state: '',
country: '',
};
// Extract address components
addressComponents.forEach(component => {
if (component.types.includes("locality")) {
address.city = component.long_name;
}
if (component.types.includes("administrative_area_level_2")) {
address.district = component.long_name;
}
if (component.types.includes("administrative_area_level_1")) {
address.state = component.long_name;
}
if (component.types.includes("country")) {
address.country = component.long_name;
}
});
displayLocationDetails(address);
} else {
document.getElementById('location-details').innerHTML = "Unable to retrieve address.";
}
})
.catch(error => {
console.error('Error fetching address:', error);
});
}
// Get current location on page load
document.addEventListener("DOMContentLoaded", function() {
if (navigator.geolocation) {
navigator.geolocation.getCurrentPosition(
function(position) {
const latitude = position.coords.latitude;
const longitude = position.coords.longitude;
getAddressFromCoordinates(latitude, longitude); // Fetch the address
},
function(error) {
document.getElementById('location-details').innerHTML = "Unable to retrieve your location.";
}
);
} else {
document.getElementById('location-details').innerHTML = "Geolocation is not supported by this browser.";
}
});
*/
</script>
<input class="package_id" name="package_id" type="hidden" value="0">
</form>POST https://cool10.vimi50.site/business/agent-register
<form method="POST" action="https://cool10.vimi50.site/business/agent-register" accept-charset="UTF-8" id="agent_register_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<div class="modal-body">
<div class="row">
<div class="box box-primary collapsed-box">
<div class="box-header with-border" data-widget="collapse" style="cursor: pointer;">
<h3 class="box-title">Basic Details</h3>
</div>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="a_date" class="label_register">Date:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-calendar"></i>
</span>
<input class="form-control" placeholder="Date" id="a_date" readonly="" required="" name="date" type="text" value="10-11-2024">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_name" class="label_register">Name:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Name" id="a_name" required="" autocomplete="on" name="name" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_address" class="label_register">Address:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="Address" id="a_address" required="" autocomplete="on" name="address" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_mobile_number" class="label_register">Mobile Number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-mobile"></i>
</span>
<input class="form-control" placeholder="Mobile Number" id="a_mobile_number" required="" name="mobile_number" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_land_number" class="label_register">Land Number:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Land Number" id="a_land_number" name="land_number" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_email" class="label_register">Email:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-envelope"></i>
</span>
<input class="form-control" placeholder="Email" id="a_email" required="" autocomplete="on" name="email" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_nic_number" class="label_register">NIC Number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-id-card-o"></i>
</span>
<input class="form-control" placeholder="NIC Number" id="a_nic_number" required="" name="nic_number" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_referral_code" class="label_register">Referral Code:</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-link"></i>
</span>
<input class="form-control" placeholder="Referral Code" id="a_referral_code" readonly="" required="" name="referral_code" type="text" value="0">
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-4">
<div class="form-group">
<label for="a_nic_copy" class="label_register">Upload NIC Image:*</label>
<input class="" id="a_nic_copy" style="margin: 0px;" name="nic_copy" type="file">
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_agent_photo" class="label_register">Upload Your Photo:</label>
<input class="" id="a_agent_photo" style="margin:
0px;" name="agent_photo" type="file">
</div>
</div>
</div>
<div class="box-footer">
</div>
</div>
<div class="box box-primary collapsed-box">
<div class="box-header with-border" data-widget="collapse" style="cursor: pointer;">
<h3 class="box-title">Bank Details</h3>
</div>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="a_bank_name" class="label_register">Bank Name:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-building"></i>
</span>
<input class="form-control" placeholder="Bank Name" id="a_bank_name" required="" name="bank_name" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_account_number" class="label_register">Account Number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-credit-card"></i>
</span>
<input class="form-control" placeholder="Account Number" id="a_account_number" required="" name="account_number" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_branch" class="label_register">Branch:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-home"></i>
</span>
<input class="form-control" placeholder="Branch" id="a_branch" style="margin: 0px !important;" required="" name="branch" type="text">
</div>
</div>
</div>
</div>
<div class="box-footer">
</div>
</div>
<div class="box box-primary collapsed-box">
<div class="box-header with-border" data-widget="collapse" style="cursor: pointer;">
<h3 class="box-title">Login Details</h3>
</div>
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="a_username" class="label_register">Username:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Username" id="a_username" readonly="" required="" autocomplete="on" name="username" type="text" value="0">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_password" class="label_register">Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>
</span>
<input name="password" type="password" value="" class="form-control" id="a_password" style="margin: 0px;">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="a_confirm_password" class="label_register">Confirm Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>
</span>
<input name="password" type="password" value="" class="form-control" id="a_confirm_password" style="margin: 0px;">
</div>
</div>
</div>
</div>
<div class="box-footer">
</div>
</div>
<div class="col-md-12">
<div class="form-group" style="padding:auto; margin-top:10px;margin-bottom:10px;">
<div class="g-recaptcha" data-sitekey="6Le0JCsdAAAAAMz-cD3AL5Xh-SOCUCaXIP8dbZmi"></div>
</div>
</div>
</div>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row">
<div class="col-md-6" style="text-align: left;">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
<div class="col-md-6" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Save</button>
</div>
</div>
</div>
<input class="package_id" name="package_id" type="hidden" value="0">
</div>
</form>POST https://cool10.vimi50.site/visitor/register
<form method="POST" action="https://cool10.vimi50.site/visitor/register" accept-charset="UTF-8" id="self_registration_form" enctype="multipart/form-data"><input name="_token" type="hidden" value="Jbz8saCyNwtQdWjk2frvTTIJ4P1FbbQHewzH7qyk">
<style>
#patient_register {
background: {
{
$login_background_color
}
}
!important;
}
label {
color: white !important;
}
</style>
<fieldset>
<div id="patient_register" style="border-radius: 5px;">
<style>
label {
color: black;
font-weight: 800;
}
</style>
<div class="modal-body">
<div class="row">
<div class="col-md-4">
<div class="form-group">
<label for="name">Name:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user"></i>
</span>
<input class="form-control" placeholder="Name" required="" autocomplete="on" name="name" type="text" id="name">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="mobile_number">Mobile Number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-mobile"></i>
</span>
<input class="form-control" placeholder="Mobile Number" required="" name="mobile_number" type="text" id="mobile_number">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="land_number">Land Number:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-phone"></i>
</span>
<input class="form-control" placeholder="Land Number" name="land_number" type="text" id="land_number">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="s_r_address">Address:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-map-marker"></i>
</span>
<input class="form-control" placeholder="Address" id="s_r_address" required="" autocomplete="on" name="address" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="s_r_district_id">District</label>
<select class="form-control select2" style="margin:0px;
width: 100%;" id="s_r_district_id" name="district_id">
<option selected="selected" value="">Please Select</option>
</select>
<div class="">
<a id="add_button_district" class="btn-modal pull-right" data-container=".view_modal" data-href="https://cool10.vimi50.site/default-district/create" style="cursor: pointer">
<i class="fa fa-plus"></i> Add</a>
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="town_id">Town</label>
<select class="form-control select2" style="margin:0px ;
width: 100%;" id="town_id" name="town_id">
<option selected="selected" value="">Please Select</option>
</select>
<div class="">
<a class="btn-modal pull-right" id="add_button_towns" data-href="https://cool10.vimi50.site/default-town/create" data-container=".view_modal" style="cursor: pointer">
<i class="fa fa-plus"></i> Add</a>
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="s_r_gender">Gender:</label>
<select name="gender" id="s_r_gender" class="form-control" required="">
<option value="">Select Gender</option>
<option value="male">Male</option>
<option value="female">Female</option>
</select>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-4">
<div class="form-group">
<label for="self_email">Email:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user-o"></i>
</span>
<input class="form-control" placeholder="Email" id="self_email" required="" autocomplete="on" name="email" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="self_username">Username:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-user-o"></i>
</span>
<input class="form-control" placeholder="Username" id="self_username" required="" autocomplete="on" name="username" type="text">
</div>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="self_password">Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>
</span>
<input class="form-control" id="self_password" style="margin: 0px;" placeholder="Password" name="password" type="password" value="">
</div>
<p class="help-block" style="color: white;">At least 6 character.</p>
</div>
</div>
<div class="col-md-4">
<div class="form-group">
<label for="self_confirm_password">Confirm Password:*</label>
<div class="input-group">
<span class="input-group-addon">
<i class="fa fa-key"></i>, </span>
<input class="form-control" id="self_confirm_password" style="margin: 0px;" placeholder="Confirm Password" name="confirm_password" type="password" value="">
</div>
</div>
</div>
</div>
</div>
<div class="clearfix"></div>
</div>
<div class="modal-footer" style="padding-top: 15px; padding-bottom: 0px;">
<div class="row">
<div class="col-md-6" style="text-align: left;">
</div>
<div class="col-md-6" style="text-align: right;">
<button class="btn btn-primary pull-right" type="submit">Submit</button>
</div>
</div>
</div>
</fieldset>
</form>Text Content
Repair Status Service Status Landing Page Login . Sign Up Sign In SIGN IN YOUR ACCOUNT Forgot Your Password? -------------------------------------------------------------------------------- Sign In If you do not have an account? Sign Up 2024 Plesae select the register type Please SelectMy Health Close Choose your Business Please SelectEzyPetRo - Ishadi Choose your Login Display Please SelectPatient DisplayPump Operator DisplayEmployee DisplayShipping DisplayProject Sales DisplayBakery Display Close Repair Status × Job sheet numberInvoice No.Vehicle NoMobile Number Search Repair Status × REGISTER YOUR VEHICLE Vehicle No: Vehicle Category: Please Select Fuel Type: Please Select Vehicle Name: District: Please Select Town: Mobile No: Land Line No: -------------------------------------------------------------------------------- Image: Passcode: Password: Date: Register Register and Get Started in minutes BUSINESS Business Name: Business contact number: Alternate contact number: Country: State: City: Zip Code: Landmark: Prefix: First Name: Last Name: Username: Email: Password: Confirm Password: -------------------------------------------------------------------------------- Submit Close Verify Register and Get Started in minutes BUSINESS Business Name: Start Date: Currency: Select CurrencyAfghanistan - Afghanis(AF) Albania - Leke(ALL) Algerie - Algerian dinar(DZD) America - Dollars(USD) Angola - Kwanza(AOA) Argentina - Pesos(ARS) Aruba - Guilders(AWG) Australia - Dollars(AUD) Azerbaijan - New Manats(AZ) Bahamas - Dollars(BSD) Bangladesh - Taka(BDT) Barbados - Dollars(BBD) Belarus - Rubles(BYR) Belgium - Euro(EUR) Beliz - Dollars(BZD) Bermuda - Dollars(BMD) Bolivia - Bolivianos(BOB) Bosnia and Herzegovina - Convertible Marka(BAM) Botswana - Pula's(BWP) Brazil - Reais(BRL) Britain [United Kingdom] - Pounds(GBP) Brunei Darussalam - Dollars(BND) Bulgaria - Leva(BG) Cambodia - Riels(KHR) Canada - Dollars(CAD) Cayman Islands - Dollars(KYD) Chile - Pesos(CLP) China - Yuan Renminbi(CNY) Colombia - Pesos(COP) Costa Rica - Colón(CRC) Croatia - Kuna(HRK) Cuba - Pesos(CUP) Cyprus - Euro(EUR) Czech Republic - Koruny(CZK) Denmark - Kroner(DKK) Dominican Republic - Pesos(DOP ) East Caribbean - Dollars(XCD) Egypt - Pounds(EGP) El Salvador - Colones(SVC) England [United Kingdom] - Pounds(GBP) Euro - Euro(EUR) Falkland Islands - Pounds(FKP) Fiji - Dollars(FJD) France - Euro(EUR) Ghana - Cedis(GHC) Gibraltar - Pounds(GIP) Greece - Euro(EUR) Guatemala - Quetzales(GTQ) Guernsey - Pounds(GGP) Guyana - Dollars(GYD) Holland [Netherlands] - Euro(EUR) Honduras - Lempiras(HNL) Hong Kong - Dollars(HKD) Hungary - Forint(HUF) Iceland - Kronur(ISK) India - Rupees(INR) Indonesia - Rupiahs(IDR) Iran - Rials(IRR) Iraq - Iraqi dinar(IQD) Ireland - Euro(EUR) Isle of Man - Pounds(IMP) Israel - New Shekels(ILS) Italy - Euro(EUR) Jamaica - Dollars(JMD) Japan - Yen(JPY) Jersey - Pounds(JEP) Kazakhstan - Tenge(KZT) Kenya - Kenyan shilling(KES) Korea [North] - Won(KPW) Korea [South] - Won(KRW) Kyrgyzstan - Soms(KGS) Laos - Kips(LAK) Latvia - Lati(LVL) Lebanon - Pounds(LBP) Liberia - Dollars(LRD) Liechtenstein - Switzerland Francs(CHF) Lithuania - Litai(LTL) Luxembourg - Euro(EUR) Macedonia - Denars(MKD) Malaysia - 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shilling(TZS) Thailand - Baht(THB) Trinidad and Tobago - Dollars(TTD) Turkey - Lira(TRY) Turkey - Liras(TRL) Tuvalu - Dollars(TVD) Uganda - Uganda shillings(UGX) Ukraine - Hryvnia(UAH) United Arab Emirates - United Arab Emirates dirham(AED) United Kingdom - Pounds(GBP) United States of America - Dollars(USD) Uruguay - Pesos(UYU) Uzbekistan - Sums(UZS) Vatican City - Euro(EUR) Venezuela - Bolivares Fuertes(VEF) Vietnam - Dong(VND) Yemen - Rials(YER) Zimbabwe - Zimbabwe Dollars(ZWD) Upload Logo: Website: Business contact number:* Alternate contact number: Country: State: City: Zip Code: Landmark: Time zone: Time 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