137 lines
4.8 KiB
PHP
137 lines
4.8 KiB
PHP
@extends('app')
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@section('content')
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<style>
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.error {
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color: red;
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}
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.g-recaptcha {
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width: 100%;
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}
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</style>
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<div class="container">
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<div class="row">
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<div class="col-md-4 col-md-offset-4">
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<div class="form-wrapper">
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<div class="panel panel-default">
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<div class="panel-heading">
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<h3 class="text-center">R E G I S T E R</h3>
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</div>
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<div class="panel-body">
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<div class="row">
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<div class="col-xs-12">
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<div id="register-response-msg"></div>
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<form role="form" id="frm-register">
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<div class="form-group text-center">
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<h5>Personal Information</h5>
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</div>
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<input type="hidden" name="redirect" value="{{ Request::get('redirectUrl') }}">
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<input type="hidden" name="_token" value="{{ csrf_token() }}">
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<div class="form-group">
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<label class="control-label">First name</label>
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<input type="text" class="form-control" name="firstname" placeholder="First name">
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</div>
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<div class="form-group">
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<label class="control-label">Last name</label>
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<input type="text" class="form-control" name="lastname" placeholder="Last name">
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</div>
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<!-- <div class="form-group">
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<label class="control-label">Username</label>
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<input type="text" class="form-control" name="username" value="{{ old('username') }}" placeholder="Username">
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</div> -->
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<div class="form-group">
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<label class="control-label">Email Address</label>
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<input type="email" class="form-control" name="email" value="{{ old('email') }}" placeholder="Email Address">
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</div>
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<div class="form-group">
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<label class="control-label">Phone Number</label>
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<input type="text" class="form-control" name="mobilenumber" placeholder="Phone Number">
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</div>
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<div class="form-group">
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<label class="control-label">Password</label>
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<input type="password" class="form-control" name="password" id="password" required placeholder="Password">
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</div>
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<div class="form-group">
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<label class="control-label">Confirm Password</label>
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<input type="password" class="form-control" name="password_confirmation" placeholder="Confirm Password" data-rule-equalTo="#password" required>
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</div>
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<div class="form-group text-center">
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<h5>Address Information</h5>
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</div>
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<div class="form-group">
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<label class="control-label">Select Country</label>
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<select name="countryCode" id="select_country" class="form-control" onchange="selectCountry(this)">
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<option value="">Select Country</option>
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<option value="US">United States</option>
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<option value="CA">Canada</option>
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</select>
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</div>
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<div class="form-group">
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<label class="control-label">State / Province</label>
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<label></label>
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<select class="form-control" name="state" id="lst-states">
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<option value="">Select State</option>
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</select>
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</div>
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<div class="form-group">
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<label class="control-label">City</label>
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<select class="form-control" name="city" id="lst-cities">
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<option value="">Select City</option>
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</select>
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</div>
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<div class="form-group">
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<label class="control-label">Address 1</label>
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<input type="text" class="form-control" name="address" placeholder="Address 1">
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</div>
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<div class="form-group">
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<label class="control-label">Address 2</label>
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<input type="text" class="form-control" name="address2" placeholder="Address 2">
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</div>
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<div class="form-group">
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<label class="control-label">Zip Code</label>
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<input type="text" class="form-control" name="zipcode" placeholder="Please enter your zip code">
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</div>
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<div class="form-group">
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<div class="g-recaptcha text-center" data-sitekey="{{ env('CAPTCHA_SITE_KEY') }}"></div>
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</div>
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<div class="form-group">
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<p>By clicking Register, you agree to our <a href="#">Terms of Use</a> and that you have read our <a href="#">Privacy Policy</a>.</p>
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</div>
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<div class="form-group">
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<button type="submit" id="btn-register" class="btn btn-primary btn-block">Register</button>
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</div>
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</form>
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</div>
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</div>
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<div class="row">
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<div class="col-xs-12">
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<hr />
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<p class="text-center">Have already an account?</p>
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<a href="{{ url('/auth/login') }}" type="submit" id="btn-login" class="btn btn-success btn-block">Login here</a>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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@endsection |