Created
January 15, 2017 15:50
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loan form
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| <!DOCTYPE html> | |
| <html lang="en"> | |
| <head> | |
| <title>Membership Form</title> | |
| <link rel="stylesheet" href="css/bootstrap.min.css"> | |
| <link rel="stylesheet" href="css/datepicker/jquery-ui.css"> | |
| <script src="css/datepicker/jquery.min.js"></script> | |
| <script src="css/datepicker/jquery-ui.min.js"></script> | |
| </head> | |
| <body> | |
| <style type="text/css"> | |
| .req | |
| { | |
| color: red; | |
| margin: 5px; | |
| } | |
| </style> | |
| <div class="container"> | |
| <center><h2>Loan Form</h2></center> | |
| <form class="form-horizontal" method="POST" action="membership_data.php" name="membership" | |
| enctype="multipart/form-data"> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Membership Number<span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="membership_number" placeholder="Membership Number"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Client Photo <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <span > | |
| <input type="file" class="btn btn-default btn-file" style="float: left;" accept="image/png, image/jpeg, image/gif" name="member_img" onchange="loadFile(event);"/> | |
| <img id="output" alt="Your Image" style="height: 70px; width: 88px; border: 1px solid #e3e3e3; border-radius: 3px;"/> | |
| </span> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Loan Applied Date & time <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <input id="datepicker" name="date_of_birth" class="btn btn-default " placeholder="Please Select Date :.:" /> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Loan Amount INR <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="Loan Amount" placeholder="Loan Amount INR"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Full Name:</label> | |
| <div class="col-sm-10"> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="full_first_name" placeholder="First Name"> | |
| <input type="text" class="form-control" name="full_last_name" placeholder="Last Name"> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Secondary Name:</label> | |
| <div class="col-sm-10"> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="second_first_name" placeholder="First Name"> | |
| <input type="text" class="form-control" name="second_last_name" placeholder="Last Name"> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Client <span class="req">*</span>:</label> | |
| <div class="col-sm-10"> | |
| <div class="radio"> | |
| <label><input type="radio" name="client" value="old">Old</label> | |
| </div> | |
| <div class="radio"> | |
| <label><input type="radio" name="client" value="new">New</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Gender <span class="req">*</span>:</label> | |
| <div class="col-sm-10"> | |
| <div class="radio"> | |
| <label><input type="radio" name="gender" value="male">Male</label> | |
| </div> | |
| <div class="radio"> | |
| <label><input type="radio" name="gender" value="female">Female</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Guarantor <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <select class="form-control" name="country" style="width:50%;"> | |
| <option value="yes">Yes</option> | |
| <option value="no">No</option> | |
| </select> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Loan Applied Date & time <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <input id="datepicker" name="date_of_birth" class="btn btn-default " placeholder="Please Select Date :.:" /> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Marital Status <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="marital_status" placeholder="Merital Status"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Name of Spouse: <span class="req">*</span></label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="spouse_name" placeholder="Name of Spouse"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Name of Father <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="father_name" placeholder="Name of Father"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Place of Birth <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="birth_place" placeholder="Place of Birth"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Photo Identification Type:</label> | |
| <div class="col-sm-4"> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="photo_id" value="voter_id_card">Voter ID Card</label> | |
| </div> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="photo_id" value="aadhar_card">Aadhar ID Card</label> | |
| </div> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="photo_id" value="other">Others</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Cheaque <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <input id="datepicker" name="date_of_birth" class="btn btn-default " placeholder="Please Select Date :.:" /> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Other Photo Identification details:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="other_photo_details" placeholder="Other Photo Identification details"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Voter ID Card Number <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="voter_id_card_number" placeholder="Voter ID Card Number"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Aadhar Card Number <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="aadhar_card_number" placeholder="Aadhar Card Number"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">PAN Card Number:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="pan_card_number" placeholder="PAN Card Number"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Present Address <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <input type="text" class="form-control" name="street_address" placeholder="Street Address"> | |
| <br /> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="city" placeholder="City"> | |
| <input type="text" class="form-control" name="state_province" placeholder="State / Province"> | |
| </div> | |
| <br /> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="postal" placeholder="Postal / Zip Code"> | |
| <select class="form-control" name="country" style="width:43%; "id="sel1"> | |
| <option> Select Country </option> | |
| <option value="Afghanistan">Afghanistan</option> | |
| <option value="Albania">Albania</option> | |
| <option value="Algeria">Algeria</option> | |
| <option value="American Samoa">American Samoa</option> | |
| <option value="Andorra">Andorra</option> | |
| <option value="Angola">Angola</option> | |
| <option value="Anguilla">Anguilla</option> | |
| <option value="Antartica">Antarctica</option> | |
| <option value="Antigua and Barbuda">Antigua and Barbuda</option> | |
| <option value="Argentina">Argentina</option> | |
| <option value="Armenia">Armenia</option> | |
| <option value="Aruba">Aruba</option> | |
| <option value="Australia">Australia</option> | |
| <option value="Austria">Austria</option> | |
| <option value="Azerbaijan">Azerbaijan</option> | |
| <option value="Bahamas">Bahamas</option> | |
| <option value="Bahrain">Bahrain</option> | |
| <option value="Bangladesh">Bangladesh</option> | |
| <option value="Barbados">Barbados</option> | |
| <option value="Belarus">Belarus</option> | |
| <option value="Belgium">Belgium</option> | |
| <option value="Belize">Belize</option> | |
| <option value="Benin">Benin</option> | |
| <option value="Bermuda">Bermuda</option> | |
| <option value="Bhutan">Bhutan</option> | |
| <option value="Bolivia">Bolivia</option> | |
| <option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option> | |
| <option value="Botswana">Botswana</option> | |
| <option value="Bouvet Island">Bouvet Island</option> | |
| <option value="Brazil">Brazil</option> | |
| <option value="British Indian Ocean Territory">British Indian Ocean Territory</option> | |
| <option value="Brunei Darussalam">Brunei Darussalam</option> | |
| <option value="Bulgaria">Bulgaria</option> | |
| <option value="Burkina Faso">Burkina Faso</option> | |
| <option value="Burundi">Burundi</option> | |
| <option value="Cambodia">Cambodia</option> | |
| <option value="Cameroon">Cameroon</option> | |
| <option value="Canada">Canada</option> | |
| <option value="Cape Verde">Cape Verde</option> | |
| <option value="Cayman Islands">Cayman Islands</option> | |
| <option value="Central African Republic">Central African Republic</option> | |
| <option value="Chad">Chad</option> | |
| <option value="Chile">Chile</option> | |
| <option value="China">China</option> | |
| <option value="Christmas Island">Christmas Island</option> | |
| <option value="Cocos Islands">Cocos (Keeling) Islands</option> | |
| <option value="Colombia">Colombia</option> | |
| <option value="Comoros">Comoros</option> | |
| <option value="Congo">Congo</option> | |
| <option value="Congo">Congo, the Democratic Republic of the</option> | |
| <option value="Cook Islands">Cook Islands</option> | |
| <option value="Costa Rica">Costa Rica</option> | |
| <option value="Cota D'Ivoire">Cote d'Ivoire</option> | |
| <option value="Croatia">Croatia (Hrvatska)</option> | |
| <option value="Cuba">Cuba</option> | |
| <option value="Cyprus">Cyprus</option> | |
| <option value="Czech Republic">Czech Republic</option> | |
| <option value="Denmark">Denmark</option> | |
| <option value="Djibouti">Djibouti</option> | |
| <option value="Dominica">Dominica</option> | |
| <option value="Dominican Republic">Dominican Republic</option> | |
| <option value="East Timor">East Timor</option> | |
| <option value="Ecuador">Ecuador</option> | |
| <option value="Egypt">Egypt</option> | |
| <option value="El Salvador">El Salvador</option> | |
| <option value="Equatorial Guinea">Equatorial Guinea</option> | |
| <option value="Eritrea">Eritrea</option> | |
| <option value="Estonia">Estonia</option> | |
| <option value="Ethiopia">Ethiopia</option> | |
| <option value="Falkland Islands">Falkland Islands (Malvinas)</option> | |
| <option value="Faroe Islands">Faroe Islands</option> | |
| <option value="Fiji">Fiji</option> | |
| <option value="Finland">Finland</option> | |
| <option value="France">France</option> | |
| <option value="France Metropolitan">France, Metropolitan</option> | |
| <option value="French Guiana">French Guiana</option> | |
| <option value="French Polynesia">French Polynesia</option> | |
| <option value="French Southern Territories">French Southern Territories</option> | |
| <option value="Gabon">Gabon</option> | |
| <option value="Gambia">Gambia</option> | |
| <option value="Georgia">Georgia</option> | |
| <option value="Germany">Germany</option> | |
| <option value="Ghana">Ghana</option> | |
| <option value="Gibraltar">Gibraltar</option> | |
| <option value="Greece">Greece</option> | |
| <option value="Greenland">Greenland</option> | |
| <option value="Grenada">Grenada</option> | |
| <option value="Guadeloupe">Guadeloupe</option> | |
| <option value="Guam">Guam</option> | |
| <option value="Guatemala">Guatemala</option> | |
| <option value="Guinea">Guinea</option> | |
| <option value="Guinea-Bissau">Guinea-Bissau</option> | |
| <option value="Guyana">Guyana</option> | |
| <option value="Haiti">Haiti</option> | |
| <option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option> | |
| <option value="Holy See">Holy See (Vatican City State)</option> | |
| <option value="Honduras">Honduras</option> | |
| <option value="Hong Kong">Hong Kong</option> | |
| <option value="Hungary">Hungary</option> | |
| <option value="Iceland">Iceland</option> | |
| <option value="India">India</option> | |
| <option value="Indonesia">Indonesia</option> | |
| <option value="Iran">Iran (Islamic Republic of)</option> | |
| <option value="Iraq">Iraq</option> | |
| <option value="Ireland">Ireland</option> | |
| <option value="Israel">Israel</option> | |
| <option value="Italy">Italy</option> | |
| <option value="Jamaica">Jamaica</option> | |
| <option value="Japan">Japan</option> | |
| <option value="Jordan">Jordan</option> | |
| <option value="Kazakhstan">Kazakhstan</option> | |
| <option value="Kenya">Kenya</option> | |
| <option value="Kiribati">Kiribati</option> | |
| <option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option> | |
| <option value="Korea">Korea, Republic of</option> | |
| <option value="Kuwait">Kuwait</option> | |
| <option value="Kyrgyzstan">Kyrgyzstan</option> | |
| <option value="Lao">Lao People's Democratic Republic</option> | |
| <option value="Latvia">Latvia</option> | |
| <option value="Lebanon" selected>Lebanon</option> | |
| <option value="Lesotho">Lesotho</option> | |
| <option value="Liberia">Liberia</option> | |
| <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option> | |
| <option value="Liechtenstein">Liechtenstein</option> | |
| <option value="Lithuania">Lithuania</option> | |
| <option value="Luxembourg">Luxembourg</option> | |
| <option value="Macau">Macau</option> | |
| <option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option> | |
| <option value="Madagascar">Madagascar</option> | |
| <option value="Malawi">Malawi</option> | |
| <option value="Malaysia">Malaysia</option> | |
| <option value="Maldives">Maldives</option> | |
| <option value="Mali">Mali</option> | |
| <option value="Malta">Malta</option> | |
| <option value="Marshall Islands">Marshall Islands</option> | |
| <option value="Martinique">Martinique</option> | |
| <option value="Mauritania">Mauritania</option> | |
| <option value="Mauritius">Mauritius</option> | |
| <option value="Mayotte">Mayotte</option> | |
| <option value="Mexico">Mexico</option> | |
| <option value="Micronesia">Micronesia, Federated States of</option> | |
| <option value="Moldova">Moldova, Republic of</option> | |
| <option value="Monaco">Monaco</option> | |
| <option value="Mongolia">Mongolia</option> | |
| <option value="Montserrat">Montserrat</option> | |
| <option value="Morocco">Morocco</option> | |
| <option value="Mozambique">Mozambique</option> | |
| <option value="Myanmar">Myanmar</option> | |
| <option value="Namibia">Namibia</option> | |
| <option value="Nauru">Nauru</option> | |
| <option value="Nepal">Nepal</option> | |
| <option value="Netherlands">Netherlands</option> | |
| <option value="Netherlands Antilles">Netherlands Antilles</option> | |
| <option value="New Caledonia">New Caledonia</option> | |
| <option value="New Zealand">New Zealand</option> | |
| <option value="Nicaragua">Nicaragua</option> | |
| <option value="Niger">Niger</option> | |
| <option value="Nigeria">Nigeria</option> | |
| <option value="Niue">Niue</option> | |
| <option value="Norfolk Island">Norfolk Island</option> | |
| <option value="Northern Mariana Islands">Northern Mariana Islands</option> | |
| <option value="Norway">Norway</option> | |
| <option value="Oman">Oman</option> | |
| <option value="Pakistan">Pakistan</option> | |
| <option value="Palau">Palau</option> | |
| <option value="Panama">Panama</option> | |
| <option value="Papua New Guinea">Papua New Guinea</option> | |
| <option value="Paraguay">Paraguay</option> | |
| <option value="Peru">Peru</option> | |
| <option value="Philippines">Philippines</option> | |
| <option value="Pitcairn">Pitcairn</option> | |
| <option value="Poland">Poland</option> | |
| <option value="Portugal">Portugal</option> | |
| <option value="Puerto Rico">Puerto Rico</option> | |
| <option value="Qatar">Qatar</option> | |
| <option value="Reunion">Reunion</option> | |
| <option value="Romania">Romania</option> | |
| <option value="Russia">Russian Federation</option> | |
| <option value="Rwanda">Rwanda</option> | |
| <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> | |
| <option value="Saint LUCIA">Saint LUCIA</option> | |
| <option value="Saint Vincent">Saint Vincent and the Grenadines</option> | |
| <option value="Samoa">Samoa</option> | |
| <option value="San Marino">San Marino</option> | |
| <option value="Sao Tome and Principe">Sao Tome and Principe</option> | |
| <option value="Saudi Arabia">Saudi Arabia</option> | |
| <option value="Senegal">Senegal</option> | |
| <option value="Seychelles">Seychelles</option> | |
| <option value="Sierra">Sierra Leone</option> | |
| <option value="Singapore">Singapore</option> | |
| <option value="Slovakia">Slovakia (Slovak Republic)</option> | |
| <option value="Slovenia">Slovenia</option> | |
| <option value="Solomon Islands">Solomon Islands</option> | |
| <option value="Somalia">Somalia</option> | |
| <option value="South Africa">South Africa</option> | |
| <option value="South Georgia">South Georgia and the South Sandwich Islands</option> | |
| <option value="Span">Spain</option> | |
| <option value="SriLanka">Sri Lanka</option> | |
| <option value="St. Helena">St. Helena</option> | |
| <option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option> | |
| <option value="Sudan">Sudan</option> | |
| <option value="Suriname">Suriname</option> | |
| <option value="Svalbard">Svalbard and Jan Mayen Islands</option> | |
| <option value="Swaziland">Swaziland</option> | |
| <option value="Sweden">Sweden</option> | |
| <option value="Switzerland">Switzerland</option> | |
| <option value="Syria">Syrian Arab Republic</option> | |
| <option value="Taiwan">Taiwan, Province of China</option> | |
| <option value="Tajikistan">Tajikistan</option> | |
| <option value="Tanzania">Tanzania, United Republic of</option> | |
| <option value="Thailand">Thailand</option> | |
| <option value="Togo">Togo</option> | |
| <option value="Tokelau">Tokelau</option> | |
| <option value="Tonga">Tonga</option> | |
| <option value="Trinidad and Tobago">Trinidad and Tobago</option> | |
| <option value="Tunisia">Tunisia</option> | |
| <option value="Turkey">Turkey</option> | |
| <option value="Turkmenistan">Turkmenistan</option> | |
| <option value="Turks and Caicos">Turks and Caicos Islands</option> | |
| <option value="Tuvalu">Tuvalu</option> | |
| <option value="Uganda">Uganda</option> | |
| <option value="Ukraine">Ukraine</option> | |
| <option value="United Arab Emirates">United Arab Emirates</option> | |
| <option value="United Kingdom">United Kingdom</option> | |
| <option value="United States">United States</option> | |
| <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option> | |
| <option value="Uruguay">Uruguay</option> | |
| <option value="Uzbekistan">Uzbekistan</option> | |
| <option value="Vanuatu">Vanuatu</option> | |
| <option value="Venezuela">Venezuela</option> | |
| <option value="Vietnam">Viet Nam</option> | |
| <option value="Virgin Islands (British)">Virgin Islands (British)</option> | |
| <option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option> | |
| <option value="Wallis and Futana Islands">Wallis and Futuna Islands</option> | |
| <option value="Western Sahara">Western Sahara</option> | |
| <option value="Yemen">Yemen</option> | |
| <option value="Yugoslavia">Yugoslavia</option> | |
| <option value="Zambia">Zambia</option> | |
| <option value="Zimbabwe">Zimbabwe</option> | |
| </select> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Landmark of Present Address <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="landmark_present_add" placeholder="Landmark of Present Address"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Office / Business Address <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <input type="text" class="form-control" name="office_business_add" placeholder="Office / Business Address"> | |
| <br /> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="office_city" placeholder="City"> | |
| <input type="text" class="form-control" name="office_state_province" placeholder="State / Province"> | |
| </div> | |
| <br /> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="office_postal" placeholder="Postal / Zip Code"> | |
| <select class="form-control" name="office_country" style="width:43%; "id="sel1"> | |
| <option> Select Country </option> | |
| <option value="Afghanistan">Afghanistan</option> | |
| <option value="Albania">Albania</option> | |
| <option value="Algeria">Algeria</option> | |
| <option value="American Samoa">American Samoa</option> | |
| <option value="Andorra">Andorra</option> | |
| <option value="Angola">Angola</option> | |
| <option value="Anguilla">Anguilla</option> | |
| <option value="Antartica">Antarctica</option> | |
| <option value="Antigua and Barbuda">Antigua and Barbuda</option> | |
| <option value="Argentina">Argentina</option> | |
| <option value="Armenia">Armenia</option> | |
| <option value="Aruba">Aruba</option> | |
| <option value="Australia">Australia</option> | |
| <option value="Austria">Austria</option> | |
| <option value="Azerbaijan">Azerbaijan</option> | |
| <option value="Bahamas">Bahamas</option> | |
| <option value="Bahrain">Bahrain</option> | |
| <option value="Bangladesh">Bangladesh</option> | |
| <option value="Barbados">Barbados</option> | |
| <option value="Belarus">Belarus</option> | |
| <option value="Belgium">Belgium</option> | |
| <option value="Belize">Belize</option> | |
| <option value="Benin">Benin</option> | |
| <option value="Bermuda">Bermuda</option> | |
| <option value="Bhutan">Bhutan</option> | |
| <option value="Bolivia">Bolivia</option> | |
| <option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option> | |
| <option value="Botswana">Botswana</option> | |
| <option value="Bouvet Island">Bouvet Island</option> | |
| <option value="Brazil">Brazil</option> | |
| <option value="British Indian Ocean Territory">British Indian Ocean Territory</option> | |
| <option value="Brunei Darussalam">Brunei Darussalam</option> | |
| <option value="Bulgaria">Bulgaria</option> | |
| <option value="Burkina Faso">Burkina Faso</option> | |
| <option value="Burundi">Burundi</option> | |
| <option value="Cambodia">Cambodia</option> | |
| <option value="Cameroon">Cameroon</option> | |
| <option value="Canada">Canada</option> | |
| <option value="Cape Verde">Cape Verde</option> | |
| <option value="Cayman Islands">Cayman Islands</option> | |
| <option value="Central African Republic">Central African Republic</option> | |
| <option value="Chad">Chad</option> | |
| <option value="Chile">Chile</option> | |
| <option value="China">China</option> | |
| <option value="Christmas Island">Christmas Island</option> | |
| <option value="Cocos Islands">Cocos (Keeling) Islands</option> | |
| <option value="Colombia">Colombia</option> | |
| <option value="Comoros">Comoros</option> | |
| <option value="Congo">Congo</option> | |
| <option value="Congo">Congo, the Democratic Republic of the</option> | |
| <option value="Cook Islands">Cook Islands</option> | |
| <option value="Costa Rica">Costa Rica</option> | |
| <option value="Cota D'Ivoire">Cote d'Ivoire</option> | |
| <option value="Croatia">Croatia (Hrvatska)</option> | |
| <option value="Cuba">Cuba</option> | |
| <option value="Cyprus">Cyprus</option> | |
| <option value="Czech Republic">Czech Republic</option> | |
| <option value="Denmark">Denmark</option> | |
| <option value="Djibouti">Djibouti</option> | |
| <option value="Dominica">Dominica</option> | |
| <option value="Dominican Republic">Dominican Republic</option> | |
| <option value="East Timor">East Timor</option> | |
| <option value="Ecuador">Ecuador</option> | |
| <option value="Egypt">Egypt</option> | |
| <option value="El Salvador">El Salvador</option> | |
| <option value="Equatorial Guinea">Equatorial Guinea</option> | |
| <option value="Eritrea">Eritrea</option> | |
| <option value="Estonia">Estonia</option> | |
| <option value="Ethiopia">Ethiopia</option> | |
| <option value="Falkland Islands">Falkland Islands (Malvinas)</option> | |
| <option value="Faroe Islands">Faroe Islands</option> | |
| <option value="Fiji">Fiji</option> | |
| <option value="Finland">Finland</option> | |
| <option value="France">France</option> | |
| <option value="France Metropolitan">France, Metropolitan</option> | |
| <option value="French Guiana">French Guiana</option> | |
| <option value="French Polynesia">French Polynesia</option> | |
| <option value="French Southern Territories">French Southern Territories</option> | |
| <option value="Gabon">Gabon</option> | |
| <option value="Gambia">Gambia</option> | |
| <option value="Georgia">Georgia</option> | |
| <option value="Germany">Germany</option> | |
| <option value="Ghana">Ghana</option> | |
| <option value="Gibraltar">Gibraltar</option> | |
| <option value="Greece">Greece</option> | |
| <option value="Greenland">Greenland</option> | |
| <option value="Grenada">Grenada</option> | |
| <option value="Guadeloupe">Guadeloupe</option> | |
| <option value="Guam">Guam</option> | |
| <option value="Guatemala">Guatemala</option> | |
| <option value="Guinea">Guinea</option> | |
| <option value="Guinea-Bissau">Guinea-Bissau</option> | |
| <option value="Guyana">Guyana</option> | |
| <option value="Haiti">Haiti</option> | |
| <option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option> | |
| <option value="Holy See">Holy See (Vatican City State)</option> | |
| <option value="Honduras">Honduras</option> | |
| <option value="Hong Kong">Hong Kong</option> | |
| <option value="Hungary">Hungary</option> | |
| <option value="Iceland">Iceland</option> | |
| <option value="India">India</option> | |
| <option value="Indonesia">Indonesia</option> | |
| <option value="Iran">Iran (Islamic Republic of)</option> | |
| <option value="Iraq">Iraq</option> | |
| <option value="Ireland">Ireland</option> | |
| <option value="Israel">Israel</option> | |
| <option value="Italy">Italy</option> | |
| <option value="Jamaica">Jamaica</option> | |
| <option value="Japan">Japan</option> | |
| <option value="Jordan">Jordan</option> | |
| <option value="Kazakhstan">Kazakhstan</option> | |
| <option value="Kenya">Kenya</option> | |
| <option value="Kiribati">Kiribati</option> | |
| <option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option> | |
| <option value="Korea">Korea, Republic of</option> | |
| <option value="Kuwait">Kuwait</option> | |
| <option value="Kyrgyzstan">Kyrgyzstan</option> | |
| <option value="Lao">Lao People's Democratic Republic</option> | |
| <option value="Latvia">Latvia</option> | |
| <option value="Lebanon" selected>Lebanon</option> | |
| <option value="Lesotho">Lesotho</option> | |
| <option value="Liberia">Liberia</option> | |
| <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option> | |
| <option value="Liechtenstein">Liechtenstein</option> | |
| <option value="Lithuania">Lithuania</option> | |
| <option value="Luxembourg">Luxembourg</option> | |
| <option value="Macau">Macau</option> | |
| <option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option> | |
| <option value="Madagascar">Madagascar</option> | |
| <option value="Malawi">Malawi</option> | |
| <option value="Malaysia">Malaysia</option> | |
| <option value="Maldives">Maldives</option> | |
| <option value="Mali">Mali</option> | |
| <option value="Malta">Malta</option> | |
| <option value="Marshall Islands">Marshall Islands</option> | |
| <option value="Martinique">Martinique</option> | |
| <option value="Mauritania">Mauritania</option> | |
| <option value="Mauritius">Mauritius</option> | |
| <option value="Mayotte">Mayotte</option> | |
| <option value="Mexico">Mexico</option> | |
| <option value="Micronesia">Micronesia, Federated States of</option> | |
| <option value="Moldova">Moldova, Republic of</option> | |
| <option value="Monaco">Monaco</option> | |
| <option value="Mongolia">Mongolia</option> | |
| <option value="Montserrat">Montserrat</option> | |
| <option value="Morocco">Morocco</option> | |
| <option value="Mozambique">Mozambique</option> | |
| <option value="Myanmar">Myanmar</option> | |
| <option value="Namibia">Namibia</option> | |
| <option value="Nauru">Nauru</option> | |
| <option value="Nepal">Nepal</option> | |
| <option value="Netherlands">Netherlands</option> | |
| <option value="Netherlands Antilles">Netherlands Antilles</option> | |
| <option value="New Caledonia">New Caledonia</option> | |
| <option value="New Zealand">New Zealand</option> | |
| <option value="Nicaragua">Nicaragua</option> | |
| <option value="Niger">Niger</option> | |
| <option value="Nigeria">Nigeria</option> | |
| <option value="Niue">Niue</option> | |
| <option value="Norfolk Island">Norfolk Island</option> | |
| <option value="Northern Mariana Islands">Northern Mariana Islands</option> | |
| <option value="Norway">Norway</option> | |
| <option value="Oman">Oman</option> | |
| <option value="Pakistan">Pakistan</option> | |
| <option value="Palau">Palau</option> | |
| <option value="Panama">Panama</option> | |
| <option value="Papua New Guinea">Papua New Guinea</option> | |
| <option value="Paraguay">Paraguay</option> | |
| <option value="Peru">Peru</option> | |
| <option value="Philippines">Philippines</option> | |
| <option value="Pitcairn">Pitcairn</option> | |
| <option value="Poland">Poland</option> | |
| <option value="Portugal">Portugal</option> | |
| <option value="Puerto Rico">Puerto Rico</option> | |
| <option value="Qatar">Qatar</option> | |
| <option value="Reunion">Reunion</option> | |
| <option value="Romania">Romania</option> | |
| <option value="Russia">Russian Federation</option> | |
| <option value="Rwanda">Rwanda</option> | |
| <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> | |
| <option value="Saint LUCIA">Saint LUCIA</option> | |
| <option value="Saint Vincent">Saint Vincent and the Grenadines</option> | |
| <option value="Samoa">Samoa</option> | |
| <option value="San Marino">San Marino</option> | |
| <option value="Sao Tome and Principe">Sao Tome and Principe</option> | |
| <option value="Saudi Arabia">Saudi Arabia</option> | |
| <option value="Senegal">Senegal</option> | |
| <option value="Seychelles">Seychelles</option> | |
| <option value="Sierra">Sierra Leone</option> | |
| <option value="Singapore">Singapore</option> | |
| <option value="Slovakia">Slovakia (Slovak Republic)</option> | |
| <option value="Slovenia">Slovenia</option> | |
| <option value="Solomon Islands">Solomon Islands</option> | |
| <option value="Somalia">Somalia</option> | |
| <option value="South Africa">South Africa</option> | |
| <option value="South Georgia">South Georgia and the South Sandwich Islands</option> | |
| <option value="Span">Spain</option> | |
| <option value="SriLanka">Sri Lanka</option> | |
| <option value="St. Helena">St. Helena</option> | |
| <option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option> | |
| <option value="Sudan">Sudan</option> | |
| <option value="Suriname">Suriname</option> | |
| <option value="Svalbard">Svalbard and Jan Mayen Islands</option> | |
| <option value="Swaziland">Swaziland</option> | |
| <option value="Sweden">Sweden</option> | |
| <option value="Switzerland">Switzerland</option> | |
| <option value="Syria">Syrian Arab Republic</option> | |
| <option value="Taiwan">Taiwan, Province of China</option> | |
| <option value="Tajikistan">Tajikistan</option> | |
| <option value="Tanzania">Tanzania, United Republic of</option> | |
| <option value="Thailand">Thailand</option> | |
| <option value="Togo">Togo</option> | |
| <option value="Tokelau">Tokelau</option> | |
| <option value="Tonga">Tonga</option> | |
| <option value="Trinidad and Tobago">Trinidad and Tobago</option> | |
| <option value="Tunisia">Tunisia</option> | |
| <option value="Turkey">Turkey</option> | |
| <option value="Turkmenistan">Turkmenistan</option> | |
| <option value="Turks and Caicos">Turks and Caicos Islands</option> | |
| <option value="Tuvalu">Tuvalu</option> | |
| <option value="Uganda">Uganda</option> | |
| <option value="Ukraine">Ukraine</option> | |
| <option value="United Arab Emirates">United Arab Emirates</option> | |
| <option value="United Kingdom">United Kingdom</option> | |
| <option value="United States">United States</option> | |
| <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option> | |
| <option value="Uruguay">Uruguay</option> | |
| <option value="Uzbekistan">Uzbekistan</option> | |
| <option value="Vanuatu">Vanuatu</option> | |
| <option value="Venezuela">Venezuela</option> | |
| <option value="Vietnam">Viet Nam</option> | |
| <option value="Virgin Islands (British)">Virgin Islands (British)</option> | |
| <option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option> | |
| <option value="Wallis and Futana Islands">Wallis and Futuna Islands</option> | |
| <option value="Western Sahara">Western Sahara</option> | |
| <option value="Yemen">Yemen</option> | |
| <option value="Yugoslavia">Yugoslavia</option> | |
| <option value="Zambia">Zambia</option> | |
| <option value="Zimbabwe">Zimbabwe</option> | |
| </select> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Landmark of Office Address <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="landmark_office_add" placeholder="Landmark of Office Address"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Nationality <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="nationality" placeholder="Nationality"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Mobile Number <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="mobile" placeholder="Mobile Number"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">E-mail:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="email" placeholder="E-mail"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Occupation <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="occupation" placeholder="Occupation"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Purpose of Loan <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="occupation" placeholder="Occupation"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Phone Number (residential):</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="residential_phone" placeholder="Phone Number (residential)"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Phone Number (office):</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="office_phone" placeholder="Phone Number (office)"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Select:</label> | |
| <div class="col-sm-10"> | |
| <div class="radio"> | |
| <label><input type="radio" name="jobtype" value="self_emp">Self Employed</label> | |
| </div> | |
| <div class="radio"> | |
| <label><input type="radio" name="jobtype" value="job">Job</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Source of Income <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="source_of_income" placeholder="Source of Income"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Transaction <span class="req">*</span>:</label> | |
| <div class="col-sm-10"> | |
| <div class="radio"> | |
| <label><input type="radio" name="transaction" value="daily_transaction">Daily Transaction</label> | |
| </div> | |
| <div class="radio"> | |
| <label><input type="radio" name="transaction" value="monthly_transaction">Monthly Transaction</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email"></label> | |
| <div class="col-sm-10"> | |
| <div class="radio"> | |
| <label><input type="radio" name="gender" value="joint_family_transaction">Joint Family Transaction</label> | |
| </div> | |
| <div class="radio"> | |
| <label><input type="radio" name="gender" value="individual">Individual</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Details of loan run from other:</label> | |
| <!-- <label for="comment">Details of loan run from other:</label> --> | |
| <div class="col-sm-4"> | |
| <textarea class="form-control" rows="5" id="comment"></textarea> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Type of loans:</label> | |
| <div class="col-sm-4"> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="type_loan" value="pay_day_loan">Pay day loan</label> | |
| </div> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="type_loan" value="business_loan">Business Loan</label> | |
| </div> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="type_loan" value="home_loan">Home Loan</label> | |
| </div> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="type_loan" value="home_application">Vehicle / Home Appliances</label> | |
| </div> | |
| <div class="checkbox"> | |
| <label><input type="checkbox" name="type_loan" value="other">Other</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Beneficiary Name <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="beneficiary" placeholder="Beneficiary"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Beneficiary Bank Name & Branch <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="beneficiary_bank_name" placeholder="Beneficiary Bank Name & Branch"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Beneficiary Bank Account No. <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="beneficiary_ac_no" placeholder="Beneficiary Bank Account No."> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Beneficiary Bank IFSC Code <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="beneficiary_ifsc_code" placeholder="Beneficiary Bank IFSC Code"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Account type <span class="req">*</span>:</label> | |
| <div class="col-sm-10"> | |
| <div class="radio"> | |
| <label><input type="radio" name="loan" value="fress_loan">Fresh Loan</label> | |
| </div> | |
| <div class="radio"> | |
| <label><input type="radio" name="loan" value="renewal_loan">Renewal Loan</label> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Days <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="days" placeholder="Days"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Guarantor Name:</label> | |
| <div class="col-sm-10"> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="guarantor_first_name" placeholder="First Name"> | |
| <input type="text" class="form-control" name="guarantor_last_name" placeholder="Last Name"> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Guarantor Photo <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <span > | |
| <input type="file" class="btn btn-default btn-file" style="float: left;" accept="image/png, image/jpeg, image/gif" name="member_img" onchange="loadFile(event);"/> | |
| <img id="output" alt="Your Image" style="height: 70px; width: 88px; border: 1px solid #e3e3e3; border-radius: 3px;"/> | |
| </span> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Guarantor Address <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <input type="text" class="form-control" name="landmark_present_add" placeholder="Landmark of Present Address"> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Office / Business Address <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <input type="text" class="form-control" name="office_business_add" placeholder="Office / Business Address"> | |
| <br /> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="office_city" placeholder="City"> | |
| <input type="text" class="form-control" name="office_state_province" placeholder="State / Province"> | |
| </div> | |
| <br /> | |
| <div class="form-inline"> | |
| <input type="text" class="form-control" name="office_postal" placeholder="Postal / Zip Code"> | |
| <select class="form-control" name="office_country" style="width:43%; "id="sel1"> | |
| <option> Select Country </option> | |
| <option value="Afghanistan">Afghanistan</option> | |
| <option value="Albania">Albania</option> | |
| <option value="Algeria">Algeria</option> | |
| <option value="American Samoa">American Samoa</option> | |
| <option value="Andorra">Andorra</option> | |
| <option value="Angola">Angola</option> | |
| <option value="Anguilla">Anguilla</option> | |
| <option value="Antartica">Antarctica</option> | |
| <option value="Antigua and Barbuda">Antigua and Barbuda</option> | |
| <option value="Argentina">Argentina</option> | |
| <option value="Armenia">Armenia</option> | |
| <option value="Aruba">Aruba</option> | |
| <option value="Australia">Australia</option> | |
| <option value="Austria">Austria</option> | |
| <option value="Azerbaijan">Azerbaijan</option> | |
| <option value="Bahamas">Bahamas</option> | |
| <option value="Bahrain">Bahrain</option> | |
| <option value="Bangladesh">Bangladesh</option> | |
| <option value="Barbados">Barbados</option> | |
| <option value="Belarus">Belarus</option> | |
| <option value="Belgium">Belgium</option> | |
| <option value="Belize">Belize</option> | |
| <option value="Benin">Benin</option> | |
| <option value="Bermuda">Bermuda</option> | |
| <option value="Bhutan">Bhutan</option> | |
| <option value="Bolivia">Bolivia</option> | |
| <option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option> | |
| <option value="Botswana">Botswana</option> | |
| <option value="Bouvet Island">Bouvet Island</option> | |
| <option value="Brazil">Brazil</option> | |
| <option value="British Indian Ocean Territory">British Indian Ocean Territory</option> | |
| <option value="Brunei Darussalam">Brunei Darussalam</option> | |
| <option value="Bulgaria">Bulgaria</option> | |
| <option value="Burkina Faso">Burkina Faso</option> | |
| <option value="Burundi">Burundi</option> | |
| <option value="Cambodia">Cambodia</option> | |
| <option value="Cameroon">Cameroon</option> | |
| <option value="Canada">Canada</option> | |
| <option value="Cape Verde">Cape Verde</option> | |
| <option value="Cayman Islands">Cayman Islands</option> | |
| <option value="Central African Republic">Central African Republic</option> | |
| <option value="Chad">Chad</option> | |
| <option value="Chile">Chile</option> | |
| <option value="China">China</option> | |
| <option value="Christmas Island">Christmas Island</option> | |
| <option value="Cocos Islands">Cocos (Keeling) Islands</option> | |
| <option value="Colombia">Colombia</option> | |
| <option value="Comoros">Comoros</option> | |
| <option value="Congo">Congo</option> | |
| <option value="Congo">Congo, the Democratic Republic of the</option> | |
| <option value="Cook Islands">Cook Islands</option> | |
| <option value="Costa Rica">Costa Rica</option> | |
| <option value="Cota D'Ivoire">Cote d'Ivoire</option> | |
| <option value="Croatia">Croatia (Hrvatska)</option> | |
| <option value="Cuba">Cuba</option> | |
| <option value="Cyprus">Cyprus</option> | |
| <option value="Czech Republic">Czech Republic</option> | |
| <option value="Denmark">Denmark</option> | |
| <option value="Djibouti">Djibouti</option> | |
| <option value="Dominica">Dominica</option> | |
| <option value="Dominican Republic">Dominican Republic</option> | |
| <option value="East Timor">East Timor</option> | |
| <option value="Ecuador">Ecuador</option> | |
| <option value="Egypt">Egypt</option> | |
| <option value="El Salvador">El Salvador</option> | |
| <option value="Equatorial Guinea">Equatorial Guinea</option> | |
| <option value="Eritrea">Eritrea</option> | |
| <option value="Estonia">Estonia</option> | |
| <option value="Ethiopia">Ethiopia</option> | |
| <option value="Falkland Islands">Falkland Islands (Malvinas)</option> | |
| <option value="Faroe Islands">Faroe Islands</option> | |
| <option value="Fiji">Fiji</option> | |
| <option value="Finland">Finland</option> | |
| <option value="France">France</option> | |
| <option value="France Metropolitan">France, Metropolitan</option> | |
| <option value="French Guiana">French Guiana</option> | |
| <option value="French Polynesia">French Polynesia</option> | |
| <option value="French Southern Territories">French Southern Territories</option> | |
| <option value="Gabon">Gabon</option> | |
| <option value="Gambia">Gambia</option> | |
| <option value="Georgia">Georgia</option> | |
| <option value="Germany">Germany</option> | |
| <option value="Ghana">Ghana</option> | |
| <option value="Gibraltar">Gibraltar</option> | |
| <option value="Greece">Greece</option> | |
| <option value="Greenland">Greenland</option> | |
| <option value="Grenada">Grenada</option> | |
| <option value="Guadeloupe">Guadeloupe</option> | |
| <option value="Guam">Guam</option> | |
| <option value="Guatemala">Guatemala</option> | |
| <option value="Guinea">Guinea</option> | |
| <option value="Guinea-Bissau">Guinea-Bissau</option> | |
| <option value="Guyana">Guyana</option> | |
| <option value="Haiti">Haiti</option> | |
| <option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option> | |
| <option value="Holy See">Holy See (Vatican City State)</option> | |
| <option value="Honduras">Honduras</option> | |
| <option value="Hong Kong">Hong Kong</option> | |
| <option value="Hungary">Hungary</option> | |
| <option value="Iceland">Iceland</option> | |
| <option value="India">India</option> | |
| <option value="Indonesia">Indonesia</option> | |
| <option value="Iran">Iran (Islamic Republic of)</option> | |
| <option value="Iraq">Iraq</option> | |
| <option value="Ireland">Ireland</option> | |
| <option value="Israel">Israel</option> | |
| <option value="Italy">Italy</option> | |
| <option value="Jamaica">Jamaica</option> | |
| <option value="Japan">Japan</option> | |
| <option value="Jordan">Jordan</option> | |
| <option value="Kazakhstan">Kazakhstan</option> | |
| <option value="Kenya">Kenya</option> | |
| <option value="Kiribati">Kiribati</option> | |
| <option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option> | |
| <option value="Korea">Korea, Republic of</option> | |
| <option value="Kuwait">Kuwait</option> | |
| <option value="Kyrgyzstan">Kyrgyzstan</option> | |
| <option value="Lao">Lao People's Democratic Republic</option> | |
| <option value="Latvia">Latvia</option> | |
| <option value="Lebanon" selected>Lebanon</option> | |
| <option value="Lesotho">Lesotho</option> | |
| <option value="Liberia">Liberia</option> | |
| <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option> | |
| <option value="Liechtenstein">Liechtenstein</option> | |
| <option value="Lithuania">Lithuania</option> | |
| <option value="Luxembourg">Luxembourg</option> | |
| <option value="Macau">Macau</option> | |
| <option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option> | |
| <option value="Madagascar">Madagascar</option> | |
| <option value="Malawi">Malawi</option> | |
| <option value="Malaysia">Malaysia</option> | |
| <option value="Maldives">Maldives</option> | |
| <option value="Mali">Mali</option> | |
| <option value="Malta">Malta</option> | |
| <option value="Marshall Islands">Marshall Islands</option> | |
| <option value="Martinique">Martinique</option> | |
| <option value="Mauritania">Mauritania</option> | |
| <option value="Mauritius">Mauritius</option> | |
| <option value="Mayotte">Mayotte</option> | |
| <option value="Mexico">Mexico</option> | |
| <option value="Micronesia">Micronesia, Federated States of</option> | |
| <option value="Moldova">Moldova, Republic of</option> | |
| <option value="Monaco">Monaco</option> | |
| <option value="Mongolia">Mongolia</option> | |
| <option value="Montserrat">Montserrat</option> | |
| <option value="Morocco">Morocco</option> | |
| <option value="Mozambique">Mozambique</option> | |
| <option value="Myanmar">Myanmar</option> | |
| <option value="Namibia">Namibia</option> | |
| <option value="Nauru">Nauru</option> | |
| <option value="Nepal">Nepal</option> | |
| <option value="Netherlands">Netherlands</option> | |
| <option value="Netherlands Antilles">Netherlands Antilles</option> | |
| <option value="New Caledonia">New Caledonia</option> | |
| <option value="New Zealand">New Zealand</option> | |
| <option value="Nicaragua">Nicaragua</option> | |
| <option value="Niger">Niger</option> | |
| <option value="Nigeria">Nigeria</option> | |
| <option value="Niue">Niue</option> | |
| <option value="Norfolk Island">Norfolk Island</option> | |
| <option value="Northern Mariana Islands">Northern Mariana Islands</option> | |
| <option value="Norway">Norway</option> | |
| <option value="Oman">Oman</option> | |
| <option value="Pakistan">Pakistan</option> | |
| <option value="Palau">Palau</option> | |
| <option value="Panama">Panama</option> | |
| <option value="Papua New Guinea">Papua New Guinea</option> | |
| <option value="Paraguay">Paraguay</option> | |
| <option value="Peru">Peru</option> | |
| <option value="Philippines">Philippines</option> | |
| <option value="Pitcairn">Pitcairn</option> | |
| <option value="Poland">Poland</option> | |
| <option value="Portugal">Portugal</option> | |
| <option value="Puerto Rico">Puerto Rico</option> | |
| <option value="Qatar">Qatar</option> | |
| <option value="Reunion">Reunion</option> | |
| <option value="Romania">Romania</option> | |
| <option value="Russia">Russian Federation</option> | |
| <option value="Rwanda">Rwanda</option> | |
| <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> | |
| <option value="Saint LUCIA">Saint LUCIA</option> | |
| <option value="Saint Vincent">Saint Vincent and the Grenadines</option> | |
| <option value="Samoa">Samoa</option> | |
| <option value="San Marino">San Marino</option> | |
| <option value="Sao Tome and Principe">Sao Tome and Principe</option> | |
| <option value="Saudi Arabia">Saudi Arabia</option> | |
| <option value="Senegal">Senegal</option> | |
| <option value="Seychelles">Seychelles</option> | |
| <option value="Sierra">Sierra Leone</option> | |
| <option value="Singapore">Singapore</option> | |
| <option value="Slovakia">Slovakia (Slovak Republic)</option> | |
| <option value="Slovenia">Slovenia</option> | |
| <option value="Solomon Islands">Solomon Islands</option> | |
| <option value="Somalia">Somalia</option> | |
| <option value="South Africa">South Africa</option> | |
| <option value="South Georgia">South Georgia and the South Sandwich Islands</option> | |
| <option value="Span">Spain</option> | |
| <option value="SriLanka">Sri Lanka</option> | |
| <option value="St. Helena">St. Helena</option> | |
| <option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option> | |
| <option value="Sudan">Sudan</option> | |
| <option value="Suriname">Suriname</option> | |
| <option value="Svalbard">Svalbard and Jan Mayen Islands</option> | |
| <option value="Swaziland">Swaziland</option> | |
| <option value="Sweden">Sweden</option> | |
| <option value="Switzerland">Switzerland</option> | |
| <option value="Syria">Syrian Arab Republic</option> | |
| <option value="Taiwan">Taiwan, Province of China</option> | |
| <option value="Tajikistan">Tajikistan</option> | |
| <option value="Tanzania">Tanzania, United Republic of</option> | |
| <option value="Thailand">Thailand</option> | |
| <option value="Togo">Togo</option> | |
| <option value="Tokelau">Tokelau</option> | |
| <option value="Tonga">Tonga</option> | |
| <option value="Trinidad and Tobago">Trinidad and Tobago</option> | |
| <option value="Tunisia">Tunisia</option> | |
| <option value="Turkey">Turkey</option> | |
| <option value="Turkmenistan">Turkmenistan</option> | |
| <option value="Turks and Caicos">Turks and Caicos Islands</option> | |
| <option value="Tuvalu">Tuvalu</option> | |
| <option value="Uganda">Uganda</option> | |
| <option value="Ukraine">Ukraine</option> | |
| <option value="United Arab Emirates">United Arab Emirates</option> | |
| <option value="United Kingdom">United Kingdom</option> | |
| <option value="United States">United States</option> | |
| <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option> | |
| <option value="Uruguay">Uruguay</option> | |
| <option value="Uzbekistan">Uzbekistan</option> | |
| <option value="Vanuatu">Vanuatu</option> | |
| <option value="Venezuela">Venezuela</option> | |
| <option value="Vietnam">Viet Nam</option> | |
| <option value="Virgin Islands (British)">Virgin Islands (British)</option> | |
| <option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option> | |
| <option value="Wallis and Futana Islands">Wallis and Futuna Islands</option> | |
| <option value="Western Sahara">Western Sahara</option> | |
| <option value="Yemen">Yemen</option> | |
| <option value="Yugoslavia">Yugoslavia</option> | |
| <option value="Zambia">Zambia</option> | |
| <option value="Zimbabwe">Zimbabwe</option> | |
| </select> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Client Signature <span class="req">*</span>:</label> | |
| <div class="col-sm-5"> | |
| <span > | |
| <input type="file" class="btn btn-default btn-file" style="float: left;" accept="image/png, image/jpeg, image/gif" name="member_img" onchange="loadFile(event);"/> | |
| <img id="output" alt="Your Image" style="height: 70px; width: 88px; border: 1px solid #e3e3e3; border-radius: 3px;"/> | |
| </span> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email">Digital Signature <span class="req">*</span>:</label> | |
| <div class="col-sm-4"> | |
| <span > | |
| <input type="file" class="btn btn-default btn-file" style="float: ;" accept="image/png, image/jpeg, image/gif" name="attached_document"/> | |
| <!-- <img id="sign" alt="Your Image" style="height: 70px; width: 88px; border: 1px solid #e3e3e3; border-radius: 3px;"/> --> | |
| </span> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <label class="control-label col-sm-2" for="email"> <span class="req">*</span></label> | |
| <div class="col-sm-4"> | |
| <span > | |
| <input type="checkbox" class="btn btn-default btn-file" name="attached_document"/> | |
| I Agree Terms Conditions | |
| </span> | |
| </div> | |
| </div> | |
| <div class="form-group"> | |
| <div class="col-sm-offset-2 col-sm-10"> | |
| <div class="form-inline"> | |
| <button type="submit" name="submit" class="btn btn-default" >Submit</button> | |
| <input type="button" class="btn btn-default" value="Print Form" onClick="window.print();" > | |
| </div> | |
| </div> | |
| </div> | |
| </form> | |
| </div> | |
| <!-- javascript for Datepicker --> | |
| <script> | |
| $(function() | |
| { $( "#datepicker" ).datepicker({ | |
| changeMonth:true, | |
| changeYear:true, | |
| yearRange:"-100:+0", | |
| dateFormat:"dd MM yy" }); | |
| }); | |
| </script> | |
| <!-- Javascript for Member image preview --> | |
| <script type="text/javascript"> | |
| var loadFile = function(event) { | |
| var reader = new FileReader(); | |
| reader.onload = function(){ | |
| var output = document.getElementById('output'); | |
| output.src = reader.result; | |
| }; | |
| reader.readAsDataURL(event.target.files[0]); | |
| }; | |
| </script> | |
| <!-- Javascript for Sign image preview --> | |
| <script type="text/javascript"> | |
| var loadFile1 = function(event1) { | |
| var reader1 = new FileReader(); | |
| reader1.onload = function(){ | |
| var output1 = document.getElementById('output1'); | |
| output1.src = reader1.result; | |
| }; | |
| reader1.readAsDataURL(event1.target.files[0]); | |
| }; | |
| </script> | |
| </body> | |
| </html> |
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