132 lines
5.1 KiB
PHP
Executable File
132 lines
5.1 KiB
PHP
Executable File
@extends('merchbay_main')
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@section('main-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="wrapper bg-white pb-5">
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<div class="main__content">
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<div class="container">
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<div class="row justify-content-center">
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<div class="col col-lg-5 pt-5 text-center text-lg-start">
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<h4>Register</h4>
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<p> <strong>Please fill in registration form to complete purchase.</strong></p>
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<hr class="custom-hr" />
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</div>
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</div>
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<div class="row justify-content-center">
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<div class="col col-lg-5">
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<div id="register-response-msg"></div>
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<form role="form" id="frm-register">
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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="text-center my-3 clearfix">
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<strong>Personal Information</strong>
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</div>
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<div class="mb-3">
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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="mb-3">
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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="mb-3">
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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="mb-3">
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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="mb-3">
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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="mb-3">
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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="mb-3">
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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="text-center my-3 clearfix">
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<strong>Address Information</strong>
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</div>
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<div class="mb-3">
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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="mb-3">
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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="mb-3">
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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="mb-3">
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<label class="control-label">Address 1</label>
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<!-- <textarea type="text" class="form-control" name="address" placeholder="Please enter your House Number, Building and Street Name"></textarea> -->
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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="mb-3">
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<label class="control-label">Address 2</label>
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<!-- <textarea type="text" class="form-control" name="address" placeholder="Please enter your House Number, Building and Street Name"></textarea> -->
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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="mb-3">
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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="mb-3">
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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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<button type="submit" class="btn btn-black btn-sm w-100 mt-3">
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Register
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</button>
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</form>
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<hr class="custom-hr" />
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<div class="py-3 text-start">
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Have already an account?
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<a href="{{ url('./auth/login') }}" class="btn btn-green btn-sm w-100">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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@endsection |