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<?php ob_start(); require_once('include/connection.php'); require_once('include/header.php'); require_once('include/navbar.php'); ?> <style> .position_1 { background-image: url("uploads/images/wallpaper/website.png"); width: 100%; object-fit: cover; } label { font-weight: 500; } </style> <section class="position_1" style="background-color:#f9ed817d"> <div class="container"> <div class="row"> <div class="col-xl-12 col-lg-12 col-md-12 col-sm-12"> <div class="card" style="border: 1px solid #00a33e !important;box-shadow: 0 4px 8px 0 rgba(0, 0, 0, 0.2), 0 6px 20px 0 rgba(0, 0, 0, 0.19); border-radius: 10px"> <div class="card-body"> <form action="mail.php" method="post"> <h3 style="text-align: center;"><span class="fcs-bold-text-white">Enquiry Form</span></h3> <hr> <div class="form-row"> <div class="col-xl-4 col-lg-4 col-md-6 col-sm-12"> <div class="form-group"> <label>Applicant Name <span style="color:red;"></span></label> <input type="text" class="form-control" name="applicant_name" placeholder="Enter Your Name" required> </div> </div> <div class="col-xl-4 col-lg-4 col-md-6 col-sm-12"> <div class="form-group"> <label>Mobile Number <span style="color:red;"></span></label> <input type="text" id="numberInput" class="form-control" name="mobile_number" maxlength="10" minlength="10" placeholder="Enter Mobile number" required> </div> </div> <div class="col-xl-4 col-lg-4 col-md-6 col-sm-12"> <div class="form-group"> <label>Email ID <span style="color:red;"></span></label> <input type="email" class="form-control" name="email_id" placeholder="Enter Your Email" required> </div> </div> <div class="col-xl-4 col-lg-4 col-md-6 col-sm-12"> <div class="form-group"> <div class="form-group txt" style="display:none"> <label> STATE <span style="color:red;" class="required"></span></label> <select name="state" id="state" class="form-control"> <option value="">Select State</option> <option value="Andhra Pradesh">Andhra Pradesh</option> <option value="Andaman and Nicobar Islands">Andaman and Nicobar Islands</option> <option value="Arunachal Pradesh">Arunachal Pradesh</option> <option value="Assam">Assam</option> <option value="Bihar">Bihar</option> <option value="Chandigarh">Chandigarh</option> <option value="Chhattisgarh">Chhattisgarh</option> <option value="Dadar and Nagar Haveli">Dadar and Nagar Haveli</option> <option value="Daman and Diu">Daman and Diu</option> <option value="Delhi">Delhi</option> <option value="Lakshadweep">Lakshadweep</option> <option value="Puducherry">Puducherry</option> <option value="Goa">Goa</option> <option value="Gujarat">Gujarat</option> <option value="Haryana">Haryana</option> <option value="Himachal Pradesh">Himachal Pradesh</option> <option value="Jammu and Kashmir">Jammu and Kashmir</option> <option value="Jharkhand">Jharkhand</option> <option value="Karnataka">Karnataka</option> <option value="Kerala">Kerala</option> <option value="Madhya Pradesh">Madhya Pradesh</option> <option value="Maharashtra">Maharashtra</option> <option value="Manipur">Manipur</option> <option value="Meghalaya">Meghalaya</option> <option value="Mizoram">Mizoram</option> <option value="Nagaland">Nagaland</option> <option value="Odisha">Odisha</option> <option value="Punjab">Punjab</option> <option value="Rajasthan">Rajasthan</option> <option value="Sikkim">Sikkim</option> <option value="Tamil Nadu">Tamil Nadu</option> <option value="Telangana">Telangana</option> <option value="Tripura">Tripura</option> <option value="Uttar Pradesh">Uttar Pradesh</option> <option value="Uttarakhand">Uttarakhand</option> <option value="West Bengal">West Bengal</option> </select> </div> </div> <!-- <div class="col-xl-4 col-lg-4 col-md-6 col-sm-12"> <div class="form-group"> <label>Select Product <span style="color:red;"></span></label> <select class="form-control" name="product" required=""> <option selected="selected" value="">Select Options</option required>> <option value="NORMAL FSSAI REGISTRATION">NORMAL FSSAI REGISTRATION</option> <option value="FSSAI STATE REGISTRATION">FSSAI STATE REGISTRATION </option> <option value="FSSAI CENTRAL REGISTRATION">FSSAI CENTRAL REGISTRATION </option> <option value="FSSAI RENEWAL">FSSAI RENEWAL </option> </select> </div> </div> <div class="form-group"> <input type="text" name="vercode" class="form-control" placeholder="Verfication Code" required="required"> </div> <div class="form-group small clearfix"> <label class="checkbox-inline">Verification Code</label>   <img src="captcha.php"> </div>--> <input type="hidden" class="form-control" name="form_name" value="FSSAI Enquiry"> <input type="hidden" class="form-control" name="form_id" value="fssai_enquiry"> <button type="submit" class="btn btn-primary fcs-submit-button">Submit Application</button> </div> </div> </form> </div> </div> </div> </div> </div> </section> <script> //Refresh Captcha function refreshCaptcha() { var img = document.images['captcha_image']; img.src = img.src.substring(0, img.src.lastIndexOf("?")) + "?rand=" + Math.random() 1000; } </script> <!-- Back To Top Button --> <?php require_once('include/footer.php'); ?>

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