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<div class="container"> |
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<form class="well form-horizontal" action=" " method="post" id="contact_form"> |
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<fieldset> |
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<!-- Form Name --> |
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<legend><center><h2><b>Registration Form</b></h2></center></legend><br> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">First Name</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="first_name" placeholder="First Name" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label" >Last Name</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="last_name" placeholder="Last Name" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Department / Office</label> |
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<div class="col-md-4 selectContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span> |
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<select name="department" class="form-control selectpicker"> |
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<option value="">Select your Department/Office</option> |
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<option>Department of Engineering</option> |
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<option>Department of Agriculture</option> |
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<option >Accounting Office</option> |
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<option >Tresurer's Office</option> |
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<option >MPDC</option> |
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<option >MCTC</option> |
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<option >MCR</option> |
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<option >Mayor's Office</option> |
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<option >Tourism Office</option> |
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</select> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Username</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="user_name" placeholder="Username" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label" >Password</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="user_password" placeholder="Password" class="form-control" type="password"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label" >Confirm Password</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="confirm_password" placeholder="Confirm Password" class="form-control" type="password"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">E-Mail</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span> |
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<input name="email" placeholder="E-Mail Address" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Contact No.</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span> |
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<input name="contact_no" placeholder="(639)" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Select Basic --> |
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<!-- Success message --> |
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<div class="alert alert-success" role="alert" id="success_message">Success <i class="glyphicon glyphicon-thumbs-up"></i> Success!.</div> |
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<!-- Button --> |
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<div class="form-group"> |
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<label class="col-md-4 control-label"></label> |
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<div class="col-md-4"><br> |
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              <button type="submit" class="btn btn-warning" >        SUBMIT <span class="glyphicon glyphicon-send"></span>        </button> |
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</div> |
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</div> |
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</fieldset> |
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</form> |
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</div> |
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</div><!-- /.container --> |