system: Linux mars.sprixweb.com 3.10.0-1160.119.1.el7.x86_64 #1 SMP Tue Jun 4 14:43:51 UTC 2024 x86_64
<AOA:output>$header</AOA:output>
<div class="container">
<div id="banner">
<h1>Human Rights Blood Donor</h1>
</div>
<AOA:output>$left</AOA:output>
<div id="right">
<div style="color:Black;">
<h2 style="background-color:Red; border-radius:5px; color:White; margin:0px; text-align:center; font-size:30px">Join Online Human Rights Blood Donor</h2><br />
<p><AOA:output>$message</AOA:output></p>
<form id="joindonor" name="joindonor" method="post" action="?do=donor&action=insert ">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="brdr" align="center">
<tbody>
<tr><th height="15" colspan="3" style="text-align:center; font-size:11px; color:#FF0000"> </th>
</tr>
<tr>
<th height="45" align="left"> Name</th>
<td width="27"><div align="center">:</div></td>
<td width="229"><input type="text" name="txtname"></td>
</tr>
<tr>
<th height="45" scope="row"><div align="left">Mobile/Phone No.</div></th>
<td><div align="center">:</div></td>
<td><input type="text" name="txtphone" onkeypress="check()"></td>
</tr>
<tr>
<th height="45" scope="row"><div align="left">Address</div></th>
<td><div align="center">:</div></td>
<td><textarea name="txtaddress" rows="2" cols="16"></textarea></td>
</tr>
<tr>
<th height="45" align="left">Village/City</th>
<td align="center">:</td>
<td align="left" id="ccity">
<select name="txtcity">
<option value="Hoshiarpur">Hoshiarpur</option>
<option value="Jalandhar">Jalandhar</option>
<option value="Amritsar">Amritsar</option>
<option value="Barnala">Barnala</option>
<option value="Bathinda">Bathinda</option>
<option value="Faridkot">Faridkot</option>
<option value="Fatehgarh Sahib">Fatehgarh Sahib</option>
<option value="Fazilka">Fazilka</option>
<option value="Firozpur">Firozpur</option>
<option value="Gurdaspur">Gurdaspur</option>
<option value="Ludhiana">Ludhiana</option>
<option value="Kapurthala">Kapurthala</option>
<option value="Mansa">Mansa</option>
<option value="Moga">Moga</option>
<option value="Ajitgarh">Ajitgarh</option>
<option value="Ropar">Ropar</option>
<option value="Muktsar">Muktsar</option>
<option value="Nawan Shahr">Nawan Shahr</option>
<option value="Sangrur">Sangrur</option>
<option value="Patiala">Patiala</option>
<option value="Pathankot">Pathankot</option>
<option value="Tarn Taran">Tarn Taran</option>
<option value="Others">Others</option>
</select>
</td>
</tr>
<tr>
<th height="45" scope="row"><div align="left">Sex</div></th>
<td><div align="center">:</div></td>
<td><div align="left">
<select name="txtsex">
<option value="Male" selected="selected">Male</option>
<option value="Female">Female</option>
</select>
</div></td>
</tr>
<tr>
<th height="45" scope="row"><div align="left">Age</div></th>
<td><div align="center">:</div></td>
<td><div align="left">
<select name="txtage">
<option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option><option value="41">41</option><option value="42">42</option><option value="43">43</option><option value="44">44</option><option value="45">45</option><option value="46">46</option><option value="47">47</option><option value="48">48</option><option value="49">49</option><option value="50">50</option><option value="51">51</option><option value="52">52</option><option value="53">53</option><option value="54">54</option><option value="55">55</option><option value="56">56</option><option value="57">57</option><option value="58">58</option><option value="59">59</option><option value="60">60</option> </select>
</div></td>
</tr>
<tr>
<th height="45" scope="row" width="25%"><div align="left">Blood Group </div></th>
<td><div align="center">:</div></td>
<td><div align="left" width="65%">
<select name="txtbgroup">
<option value="A+">A+</option><option value="A-">A-</option><option value="B+">B+</option><option value="B-">B-</option><option value="O+">O+</option><option value="O-">O-</option><option value="AB+">AB+</option><option value="AB-">AB-</option><option value="Not Known">Not Known</option> </select>
</div></td>
</tr>
<tr><td> </td></tr>
<tr>
<th height="38" colspan="3" align="center"><input type="submit" name="Submit" value="Submit"> <input type="reset" value="Reset"></th>
</tr>
<tr><td> </td></tr><tr><td> </td></tr><tr><td> </td></tr>
<tr>
<th height="0" colspan="3" align="center"><p><b> Note</b> Please visit at People For Human Rights office within week from registration date or call us @ (M) +91-98152-32633 or (O) +91-183-2424447 </p>
</th>
</tr>
</tbody></table>
</form>
</div>
</div>
</div>
<AOA:output>$footer</AOA:output>