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Direktori : /home/importfo/www/advancedentalcancerhospital.com/
Upload File :
Current File : /home/importfo/www/advancedentalcancerhospital.com/popup123.php

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<head>
	<meta charset="UTF-8">
	<title>Admission Open || Siya Education Zone, Gandhinagar.</title>


	<!-- Mobile Specific Meta -->
	<meta name="viewport" content="width=device-width, initial-scale=1">

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	<style type="text/css">
		.payment-method { display: block!important;}
		
	</style>
</head>

<body>

	<!-- <div id="preloader"></div> -->

		<!-- 	<div id="switch-color" class="color-switcher">
		<div class="open"><i class="fas fa-cog fa-spin"></i></div>
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			<li><a class="color-2" onclick="setActiveStyleSheet('color-2'); return true;" href="#!"><i class="fas fa-circle"></i></a> </li>
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		<button class="switcher-light">WIDE </button>
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		<a class="rtl-v" href="RTL_Genius/index.html">RTL </a>
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	<!-- Start of Header section
		============================================= -->
		<?php include("top.php") ?>
 	<!-- Start of Header section
 		============================================= --> 


	<!-- Start of breadcrumb section
		============================================= -->
		<section id="breadcrumb" class="breadcrumb-section relative-position backgroud-style">
			<img src="banner/admittion.png" style="position: absolute; height: 100%;">
			<div class="blakish-overlay"></div>
			<div class="container">
				<div class="page-breadcrumb-content text-center">
					<div class="page-breadcrumb-title">
						<h2 class="breadcrumb-head black bold">New <span>Admission</span></h2>
					</div>
					<div class="page-breadcrumb-item ul-li">
						<ul class="breadcrumb text-uppercase black">
							<li class="breadcrumb-item"><a href="index,php">Home</a></li>
							<li class="breadcrumb-item active">New Admission</li>
						</ul>
					</div>
				</div>
			</div>
		</section>
	<!-- End of breadcrumb section
		============================================= -->


	<!-- Start of Checkout content
		============================================= -->
		<section id="checkout" class="checkout-section">
			<div class="container">
				<div class="section-title mb45 headline text-center">
					<span class="subtitle text-uppercase">Admission Form</span>
					<h2>Admission<span> </span></h2>
				</div>
				<div class="checkout-content">
					<div class="row">
						<div class="col-md-2"></div>
						<div class="col-md-8">
							<div class="order-payment">
								<div class="payment-method">
									<div class="check-out-form">
										<form action="admission-inquiry.php" method="post" class="">	
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label">Name :</label>
											    <div class="col-sm-9">
											    	<span style="color: red;">*</span>
											      	<input type="text" class="form-control" name="name" placeholder="Enter Name" required="">
											    </div>
											</div>
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label">Email Address :</label>
											    <div class="col-sm-9">
											    	<span style="color: red;">*</span>
											    	<input type="text" class="form-control" name="email" placeholder="Enter Email" required="">

												</div>
											</div>
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label">Contact :</label>
											    <div class="col-sm-9">
											    	<span style="color: red;">*</span>
											    	<input type="text" class="form-control" name="contact" placeholder="Enter Contact" required="">
												</div>
											</div>
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label">Date:</label>
											    <div class="col-sm-9">
											    	<input type="date" class="form-control" name="date1" placeholder="DD/MM/YYYY" required="">
											    </div>
											</div>
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label">Cources :</label>
											    <div class="col-sm-9">
											    	<select class="form-control" name="cources">
														<option value="0">---- Select Cources ---</option>
														
														<option value="8 to 12 Guj Mid">8 to 12 Guj Mid</option>
														<option value="6 to 12 Eng Mid">6 to 12 Eng Mid</option>
														<option value="NMMS exam">NMMS Exam</option>
														<option value="Prakharta Exam">Prakharta Exam</option>
														<option value="NTSE Exam">NTSE Exam</option>
													</select>
											    </div>
											</div>
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label">Message :</label>
											    <div class="col-sm-9">
											      <textarea class="form-control" name="msg" placeholder="Enter Text Here.."></textarea>
											    </div>
											</div>
											<div class="form-group row">
											    <label for="inputPassword" class="col-sm-3 col-form-label" style="visibility: hidden;">Message :</label>
												<div class="col-sm-9">
											    	<button type="Submit" class="btn btn-primary" name="submit">Submit</button>
											    </div>
											</div>
										</form>
									</div>
								</div>
							</div>
						</div>
					</div>
				</div>
			</div>
		</section>
	<!-- End  of Checkout content
		============================================= -->



	<!-- Start of footer section
		============================================= -->
		<?php include("footer.php") ?>
	<!-- End of footer section
		============================================= -->



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