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index.html
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<!DOCTYPE html>
<html lang="en">
<head>
<script type="text/javascript" src="https://codesandbox.io/public/sse-hooks/sse-hooks.js"></script>
<meta charset="UTF-8" />
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
<meta http-equiv="X-UA-Compatible" content="ie=edge" />
<title>Vithai-form</title>
<link
rel="stylesheet"
href="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/css/bootstrap.min.css"
integrity="sha384-ggOyR0iXCbMQv3Xipma34MD+dH/1fQ784/j6cY/iJTQUOhcWr7x9JvoRxT2MZw1T"
crossorigin="anonymous"
/>
<link
rel="stylesheet"
href="https://cdn.rawgit.com/tonystar/bootstrap-float-label/v4.0.2/bootstrap-float-label.min.css"
/>
</head>
<style>
* {
margin: 0;
padding: 0;
}
.body {
margin: 5px;
}
.border {
border: 1px solid #666 !important;
}
.form-control {
border: 1px solid #555 !important;
}
.card {
border: 1px solid #666 !important;
}
.row {
margin-right: 0;
margin-left: 0;
}
.image-holder {
float: right;
width: 200px;
height: 220px;
}
.form-control.textarea {
height: 90px;
}
.form-control.address-textarea {
height: 90px;
}
.card-body.singnature-card {
padding: 35px 20px 0px;
}
.custom-control.custom-checkbox {
padding-left: 10px;
}
.no-gutter {
padding: 5px 0
}
.card-title {
margin-bottom: 5px;
}
.sign-padding {
padding-right: 150px;
}
.status-padding {
padding-right: 180px;
}
.status-card {
padding: 10px 0;
}
.status-card .date-padding {
padding-left: 100px;
}
.date-padding {
padding-left: 75px;
}
.bg-img {
content: "";
display: block;
position: absolute;
z-index: -1;
width: 600px;
height: 600px;
background-image: url('https://uploads.codesandbox.io/uploads/user/53eb2c21-1661-4e4b-810b-2ea357edb44f/YHfm-vithai-logo.png');
background-position: center;
background-size: cover;
opacity: 0.2;
top: 30%;
left: 25%;
bottom: 100;
right: 0;
}
</style>
<body class="body border">
<div class="bg-img"></div>
<div class="media position-relative border-bottom m-1 pb-4 p-1">
<img class="mt-1" src="https://uploads.codesandbox.io/uploads/user/53eb2c21-1661-4e4b-810b-2ea357edb44f/YHfm-vithai-logo.png" height="220px" class="mr-3" alt="...">
<div class="card-body">
<div class="mx-auto mt-5" style="width: 450px;">
<h1 class="mx-auto mb-2" style="width: 400px;"><b>விதை அறக்கட்டளை</b></h1>
<h3 class="mx-auto" style="width: 380px;">கல்வி நிதியுதவி விண்ணப்பம்</h3>
<h6 class="mx-auto" style="width: 300px;">contact: [email protected]</h6>
</div>
</div>
<div class="border image-holder mt-4 mr-4">
<svg class="bd-placeholder-img card-img-top" width="100%" height="180" xmlns="http://www.w3.org/2000/svg" preserveAspectRatio="xMidYMid slice" focusable="false" role="img" aria-label="Placeholder: Image cap">
<title>Placeholder</title><rect width="100%" height="100%" fill="#fff"></rect>
<text x="20%" y="55%" fill="#ccc" dy=".3em">Affix Your Passport </text>
<text x="35%" y="65%" fill="#ccc" dy=".3em">Size Photo</text>
</svg>
</div>
</div>
<div class="col-md-12">
<form>
<h4 class="mb-3 mt-2">Personal Details</h4>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Name</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Occupation(Father / Mother / Guardian)</span>
</label>
</div>
</div>
<div class="form-group input-group">
<div class="col-md-6">
<label class="custom-control custom-checkbox">
<span class="custom-control-description">Sex: </span>
<input class="" type="checkbox" />
<span class="custom-control-description"> Male </span>
<input class="" type="checkbox" />
<span class="custom-control-description"> Female </span>
<input class="" type="checkbox" />
<span class="custom-control-description"> Others </span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" value="₹"/>
<span>Monthly Income </span>
</label>
</div>
</div>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Date of Birth</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" value=""/>
<span>Contact Number </span>
</label>
</div>
</div>
<div class="form-group input-group">
<div class="col-md-6">
<div class="col-md-12 no-gutter">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Father's Name</span>
</label>
</div>
<div class="col-md-12 no-gutter">
<label class="has-float-label">
<input class="form-control" type="text" value="" />
<span>Mother's Name</span>
</label>
</div>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control textarea address-textarea" type="text" />
<span>Address (Door No, Street and City)</span>
</label>
</div>
</div>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" value="" />
<span>Guardian's Name</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Year of most recent sponsorship received from Vithai (If applicable) ?</span>
</label>
</div>
</div>
</form>
</div>
<div class="col-md-12 mb-3">
<form>
<h4 class="mb-3 mt-2">Educational Details </h4>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Acadmic Year</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>School Details (School Name and City)</span>
</label>
</div>
</div>
<div class="form-group input-group ">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Class</span>
</label>
</div>
<div class="col-md-6">
<div class="col-md-12 no-gutter">
<label class="custom-control custom-checkbox">
<span class="custom-control-description">
Required for :
</span>
<input class="" type="checkbox" />
<span class="custom-control-description"> Tuition Fee</span>
<input class="" type="checkbox" />
<span class="custom-control-description"> Notebook </span>
<input class="" type="checkbox" />
<span class="custom-control-description"> Others </span>
</label>
</div>
</div>
</div>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Medium</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" value="₹" />
<span>Amount</span>
</label>
</div>
</div>
</form>
<div class="col-md-12">
<div class="card p-1 mb-3">
<div class="card-body">
<h5 class="card-title"><b>விதிமுறைகள் </b></h5>
<p class="card-text">
<small>
<span>1. முழுமையாக பூர்த்தி செய்யப்படாத விண்ணப்பங்கள் பரிசீலனைக்கு எடுத்துக் கொள்ளப்படாது.</span></br>
<span>2. கல்வி நிதியுதவி பெரும் மாணவர்கள், பணம் செலுத்தியதற்கான ரசீதை தவறாது சமர்ப்பிக்க வேண்டும்.</span></br>
<span>3. அனைத்து விண்ணப்பங்களும் பரிசீலிக்கப்பட்டு, தேர்ந்தெடுக்கப்பட்ட மாணவர்களுக்கு மட்டும் அவரை வழிமொழிந்தவர்கள் வழியே தெரிவிக்கப்படும்.</span></br>
<span>4. அறக்கட்டளையின் முடிவே இறுதியானது. </span>
</small>
</p>
</div>
</div>
<div class="card p-1">
<div class="card-body singnature-card">
<p class="card-text">
<small><span class="date-padding"> Date </span></small>
<small><span class="float-right sign-padding"> Student's Signature </span></small>
</p>
</div>
</div>
</div>
</div>
<div class="col-md-12 border-top mb-3">
<form>
<h4 class="mb-3 mt-2">Referrer Details </h4>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Name</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Occupation</span>
</label>
</div>
</div>
<div class="form-group input-group">
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Relationship to the student</span>
</label>
</div>
<div class="col-md-6">
<label class="has-float-label">
<input class="form-control" type="text" />
<span>Contact Number</span>
</label>
</div>
</div>
</form>
<div class="col-md-12">
<div class="card p-1">
<div class="card-body singnature-card">
<p class="card-text">
<small><span class="date-padding"> Date </span></small>
<small><span class="float-right sign-padding"> Referrer's Signature </span></small>
</p>
</div>
</div>
</div>
</div>
<div class="col-md-12 border-top mt-1">
<h6 class="mb-3 mt-2">Office Use Only </h6>
<div class="card m-3">
<div class="card-body status-card">
<p class="card-text">
<small><span class="date-padding"> Date </span></small>
<small><span class="float-right status-padding"> Approval Status </span></small></br>
</p>
</div>
</div>
<div>
<!-- End of row div-->
<script crossorigin type="text/javascript" src="https://codesandbox.io/static/js/watermark-button.ccc763f75.js"></script>
</body>
</html>