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Registration Form Agent Agent Code: Name: Date of Birth: Address

This document contains an HTML registration form with fields for an agent's code, name, date of birth, address, pincode, branch, contact number, and buttons to submit or reset the form. The form uses CSS styling and requires input for all fields before submission, validating the agent code and contact number patterns.

Uploaded by

Aishah amslah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
53 views

Registration Form Agent Agent Code: Name: Date of Birth: Address

This document contains an HTML registration form with fields for an agent's code, name, date of birth, address, pincode, branch, contact number, and buttons to submit or reset the form. The form uses CSS styling and requires input for all fields before submission, validating the agent code and contact number patterns.

Uploaded by

Aishah amslah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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<html>

<head>

<title>Registration Form</title>

</head>

<body>

<link href = "registration.css" type = "text/css" rel = "stylesheet" />

<h2>Agent</h2>

<form name = "form1" action='modified.php' method = 'POST' enctype =


"multipart/form-data" >

<div class = "container">

<div class = "form_group">

<label>Agent Code:</label>

<input type = "text" name = "Agent_code" required pattern="[0-


9]{3}[A-Z a-z]{3}[0-9]{3}"/>

</div>

<div class = "form_group">

<label>Name:</label>

<input type = "text" name = "Agent_Name" value = "" required />

</div>

<div class = "form_group">

<label>Date of Birth: </label><input type = "date" name =


"DOB" value = "" required />

</div>

<div class = "form_group">

<label>Address:</label>

<input type = "text" name = "Address" value = "" required />

</div>

<div class = "form_group">


<label>Pincode: </label>

<input type = "text" name = "Pincode" value = "" required />

</div>

<div class = "form_group">

<label>Branch: </label>

<input type = "text" name = "Branch" value = "" required" />

</div>

<div class = "form_group">

<label>Contact Number: </label>

<input type = "text" name = "Contact_Number" value = ""


required pattern="[0-9]{10}" />

</div>

<div class = "form_group">

<input type = "submit" value = "submit"/>

</div>

<div class = "form_group">

<input type = "reset" value = "reset"/>

</div>

<div class = "form_group">

<label><a href="../index.php">Back to homepage</a></label>

</div>

</div>

</form>

</body>

</html>

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