<?php include '../layouts/header2.php';?>

 <!-- Content Wrapper. Contains page content -->
  <div class="content-wrapper">
    <!-- Content Header (Page header) -->
    <div class="content-header">
      <div class="container-fluid">
        <div class="row mb-2">
          <div class="col-sm-6">
            <h1 class="m-0"> OFFICE REQUEST</h1>
          </div><!-- /.col -->
          <div class="col-sm-6">
            <ol class="breadcrumb float-sm-right">
              <li class="breadcrumb-item"><a href=" #">MASTER </a></li>
              <li class="breadcrumb-item active"> OFFICE REQUEST</li>
            </ol>
          </div><!-- /.col -->
        </div><!-- /.row -->
      </div><!-- /.container-fluid -->
    </div>
    <!-- /.content-header -->

    <!-- Main content -->
    <section class="content">
      <div class="container-fluid">
        <!-- form -->
        <div class="row">
          <!-- left column -->
          <div class="col-md-12">
            <!-- general form elements -->
            <div class="card card-primary">
              <div class="card-header">
                <h3 class="card-title"> Office Details</h3>
              </div> 
              <!-- /.card-header -->
              <!-- form start -->
              <form class="form-horizontal">
                <div class="card-body">
                  <div class="form-group row"> 
                    <label class="col-sm-2 col-form-label">Reference By	</label>
                    <div class="col-sm-2">
                    <select class="form-control">
                            <option>-----SELECT-----</option>
                            <option>Agent</option>
                            <option>Employee</option> 
                    </select> 
                    </div> 
                    <label  class="col-sm-2 col-form-label">Reference Name	</label>
                    <div class="col-sm-2"> 
                    <input type="text" class="form-control form-control-sm">
                    </div>  
                    <label  class="col-sm-2 col-form-label">Office Name	</label>
                    <div class="col-sm-2"> 
                    <input type="text" class="form-control form-control-sm">
                    </div> 
                    </div>
                    <div class="form-group row"> 
                    <label  class="col-sm-2 col-form-label">Plan Adopted		</label>
                    <div class="col-sm-2"> 
                    <select class="form-control">
                            <option>-----SELECT-----</option>
                            <option>Silver</option>
                            <option>Gold</option> 
                    </select> 
                    </div> 
                    <div class="col-md-2">
                    <div class="form-group">
                    <div class="form-check">
                    <input type="checkbox" class="form-check-input">
                    <label class="form-check-label">Amount Paid</label>
                  </div>
                </div>
                </div> 
                <div class="col-md-2">
                    <div class="form-group">
                    <div class="form-check">
                    <input type="checkbox" class="form-check-input">
                    <label class="form-check-label"> Deposit Amount</label>
                  </div>
                </div>
                </div> 
                </div>
                  <div class="row">
                    <div class="col-md-6">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">Contact Person</h3>
              </div>   
              <div class="row">
              <div class="card-body">
                  <div class="row">
                  <div class="col-md-8">
                    <div class="form-group">
                    <label>Name</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                </div> 
                  <div class="col-md-4">
                  <div class="form-group">
                    <label >Mobile</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-6">
                  <div class="form-group">
                    <label >Phone</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-6">
                  <div class="form-group">
                    <label >Personal No</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-8">
                  <div class="form-group">
                    <label >EMail</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
            </div>
            </div> 
                  </div>
                  </div>
                </div>
                <div class="col-md-6">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">Address</h3>
              </div>   
              <div class="card-body">
              <div class="row">
                    <div class="col-md-12">
                    <div class="form-group">
                    <label>Address</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                  </div>
                  <div class="col-md-6">
                    <div class="form-group">
                    <label>Pincode</label>
                    <input type="text" class="form-control form-control-sm">
                  </div>
                  </div>
                  <div class="col-md-6">
                    <div class="form-group">
                    <label>City</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                  </div>
                  <div class="col-md-6">
                    <div class="form-group">
                    <label>State	</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                  </div> 
                  </div> 
                  </div>
                  </div>
                </div>
                </div>
                <div class="row">
                    <div class="col-md-12">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">Other Details</h3>
              </div>   
              <div class="row">
              <div class="card-body">
                  <div class="row">
                  <div class="col-md-4">
                    <div class="form-group">
                    <label>PAN Number	</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                </div> 
                  <div class="col-md-4">
                  <div class="form-group">
                    <label >Service Tax Number	</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
            </div>
            </div> 
                  </div>
              </div>
                <div class="row">
                    <div class="col-md-12">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">Upload Documents</h3>
              </div>   
              <div class="row">
              <div class="card-body">
                  <div class="row">
                  <div class="col-md-4">
                    <div class="form-group">
                    <label>Document 1 *	</label>
                    <input type="file" class="form-control "  >
                  </div>
                </div> 
                  <div class="col-md-4">
                  <div class="form-group">
                    <label >Document 2 *	</label>
                    <input type="file" class="form-control " >
                  </div>
                </div> 
                <div class="col-md-4">
                    <div class="form-group">
                    <label>Document 3 *	</label>
                    <input type="file" class="form-control "  >
                  </div>
                </div> 
                  <div class="col-md-4">
                  <div class="form-group">
                    <label >Document 4 *	</label>
                    <input type="file" class="form-control " >
                  </div>
                </div> 
                <div class="col-md-4">
                    <div class="form-group">
                    <label>Document 5 *	</label>
                    <input type="file" class="form-control "  >
                  </div>
                </div> 
                  <div class="col-md-4">
                  <div class="form-group">
                    <label >Document 6 *	</label>
                    <input type="file" class="form-control " >
                  </div>
                </div> 
            </div>
            </div> 
                  </div>
                  </div>
                </div>
            </div> 
                <!-- /.card-body -->
                <div class="card-footer">
                  <button type="submit" class="btn btn-info">Save</button>
                </div>
                <!-- /.card-footer -->
              </form>
        <!-- form -->
      </div><!-- /.container-fluid -->
    </section>
    <!-- /.content -->
  </div>
  <!-- /.content-wrapper -->
  <?php include '../layouts/footer1.php';?>