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_BaDConfirmation_preview.html
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_BaDConfirmation_preview.html
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<html>
<Head><b>Birth Certificate Confirmation</b></head><br><br><br>
<body onload="hidecontent()">
<script type="text/javascript">
function showDiv() {
document.getElementById('welcomeDiv').style.display = "block";
}
function hidecontent()
{
document.getElementById('welcomeDiv').style.display = "allow";
}
</script>
<table>
<tr>Application Reference Number: ARN02349 </tr><br>
<tr>ULB: Corporation</tr><br>
<tr>Corporation Name: Coimbatore</tr><br>
<tr>Ward Number: Coimbatore (M Corp.) WARD NO.-0124</tr><br>
<tr>Hospital Name: PSG Hospitals</tr><br>
<tr>Hospital Address: No17, Peelamedu, Combatore, TamilNadu-612345</tr><br>
<tr>Father Name: S Shanmugam</tr><br>
<tr>Mother Name: Rajeswari</tr><br>
<tr>Place of Birth: Coimbatore</tr><br>
<tr>Permanent Address: No28, South Mada Street, Saiddapet, Chennai - 600008</tr><br>
<tr>Gender: Male</tr><br>
<tr>Date of Birth and
Time: 22-Mar-2012 8:00 AM</tr><br>
</table>
<div id="welcomeDiv" style="display:none">
<table name="hospital" onload="display:none">
Hospital details
Application Number <input type="text" ></input><br>
<br>
Select Corporation
<select>
<option value=""></option>
<option value="Coimbatore">Coimbatore</option>
<option value="Madurai">Madurai</option>
<option value="Tirichurapalli">Tirichurapalli</option>
<option value="Salem">Salem</option>
<option value="Tirunelvelli">Tirunelvelli</option>
<option value="Tirupur">Tirupur</option>
<option value="Erode">Erode</option>
<option value="Thoothukudi">Thoothukudi</option>
<option value="Vellore">Vellore</option>
</select>
<br>
Select Municpality
<select>
<option value=""></option>
<option value="Thuraiyur">Thuraiyur</option>
<option value="Coonoor">Coonoor</option>
<option value="Arani">Arani</option>
<option value="Tambaram">Tambaram</option>
</select>
<br>
Select Town Panchayat
<select>
<option value=""></option>
<option value="Upiliyapuram">Upiliyapuram</option>
<option value="Sholinganallur">Sholinganallur</option>
<option value="Vengaivasal">Vengaivasal</option>
</select>
<br>
Ward Number
<input type="text" ></input>
<br>
Father name
<input type="text" ></input>
<br>
Mother Name
<input type="text" ></input>
<br>
Gender <input type="radio" name="gender"></input>Male <input type="radio" name="gender"></input>Female
</select><br>
Date of Birth
Day
<select>
<option value=""></option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<br>
</select>
</select>
Month
<select>
<option value=""></option>
<option value="Jan">Jan</option>
<option value="Feb">Feb</option>
<option value="Mar">Mar</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="Jun">June</option>
<option value="Jul">July</option>
<option value="Aug">Aug</option>
<option value="Sep">Sep</option>
<option value="Oct">Oct</option>
<option value="Nov">Nov</option>
<option value="Dec">Dec</option>
<br>
</select>
Year
<select>
<option value=""></option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<br>
</select>
Time Hours
<select>
<option value=""></option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<br>
</select>
Mins
<select>
<option value=""></option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<br>
</select>
<br>
<a href="BaDConfirmation.html">
<input type="button" value="Register">
</a>
</table>
</div>
</body>
<a href="IULBG.html">Return to home page</a>
<html>