rtms/signup.php at master · amims71/rtms · GitHub

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<?php

include 'head.php';
?>

<div class="main">
     <div class="wrap">
      	 <div class="section group">
				<div class="cont span_2_of_blog">
				  <div class="login-title">
           		<h4 class="title">User Signup</h4>
				<div id="loginbox" class="loginbox">
					<form action="insert.php" method="post" name="login" id="login-form">
					  <fieldset class="input">
					    <p id="login-form-username">
					      <label for="modlgn_username">Full Name</label>
					      <input id="modlgn_username" type="text" name="name" class="inputbox" size="18" autocomplete="off" required >
					    </p>
						<p>
					      <label for="modlgn_username">UserName</label>
					      <input id="modlgn_username" type="text" name="username" class="inputbox" size="18" autocomplete="off" required >
					    </p>
						<p>
					      <label for="modlgn_username">Address</label>
					      <input id="modlgn_username" type="text" name="address" class="inputbox" size="18" autocomplete="off" required >
					    </p>
						<p >
					      <label for="modlgn_username">Mobile Number</label>
					      <input id="modlgn_username" type="text" name="mobile" class="inputbox" size="18" autocomplete="off" required >
					    </p>
						<p >
					      <label for="modlgn_username">Email</label>
					      <input id="modlgn_username" type="text" name="email" class="inputbox" size="18" autocomplete="off" required >
					    </p>
						<p >
					      <label for="modlgn_username">Bank Name</label>
					      <input id="modlgn_username" type="text" name="bankname" class="inputbox" size="18" autocomplete="off" required >
					    </p>

						<p >
					      <label for="modlgn_username">Bank A/C Number</label>
					      <input id="modlgn_username" type="text" name="acn" class="inputbox" size="18" autocomplete="off" required >
					    </p>

					    <p id="login-form-password">
					      <label for="modlgn_passwd">Password</label>
					      <input id="modlgn_passwd" type="password" name="password" class="inputbox" size="18" autocomplete="off" required>
					    </p>
					    <p id="login-form-remember">
					      <label for="modlgn_remember" class="checkbox">I Have Accepted RTMS Policy</label>
					      <input id="modlgn_remember" type="checkbox" name="remember" class="checkbox" value="yes" autocomplete="off" required>
					    </p>
					    <input type="submit" name="Submit" class="button" value="Signup">
					  </fieldset>
					 </form>

				</div>
			</div>
			</div>
		  <div class="bsidebar span_1_of_blog">


	     </div>
	   </div>
	   <div class="clear"></div>
	  </div>
   </div>


<?php
include 'footer.php';

?>