<!
DOCTYPE html>
<html>
<head>
<meta charset='utf-8'>
<meta http-equiv="X-UA-Compatible" content="IE-edge">
<title>Mercury Drug Delivery Service</title>
</head>
<style>
input[type="file"] {
background: transparent;
width: 100%;
}
input[type="text"] {
background: transparent;
width: 100%;
}
input[type="number"] {
background: transparent;
width: 100%;
}
input[type="email"] {
background: transparent;
width: 100%;
}
input[type="tel"] {
background: transparent;
width: 100%;
}
input[type="url"] {
background: transparent;
width: 100%;
}
input[type="checkbox"] {
background: transparent;
input[type="button"] {
background: transparent;
}
input[type="checkbox"] /* Fill here */ :checked + a {
/* Fill the attribute and value */
}
body{
font-weight: bold;
margin-left: auto;
margin-right: auto;
}
h3{
color: #FFFFFF;
background-color: #800000;
margin-left: auto;
margin-right: auto;
text-align: center;
width: 60%;
font-family: Verdana;
padding: 3px;
border-radius: 6px;
}
table{
width: 60%;
border-style:3px solid;
margin-left: auto;
margin-right: auto;
border-spacing: 5px;
border-radius: 6px;
}
td{
font-size: 15px;
}
#submit{
color:#800000;
font-weight: bold;
background: transparent;
border-radius: 6px;
}
#submit:hover {
background-color:#800000 ;
color: #FFFFFF;
}
.a{
width: 50%;
}
.b{
width: 60%;
}
::-webkit-input-placeholder {
color: #dcdcdc;
}
</style>
<body>
<h3> Mercury Drug Delivery Service-Partner Invite </h3>
<table style="text-align: left;">
<tr>
<td colspan="2"><input type="text" required id="pharmacyName"
placeholder="Pharmacy name*"></td>
</tr>
<tr>
<td class="a"><input type="number" id="pin"
placeholder="Pin(PrimaryLocation)*" required></td>
<td><input type="text" id="city" placeholder="City*"></td>
</tr>
<tr>
<td class="a"><input type="text" id="oname" placeholder="Pharmacy
owner*" required</td>
<td><input type="tel" id="phno" placeholder="Phone number*"
pattern="[7-9]{1}[0-9]{9}" required></td>
</tr>
<tr>
<td colspan="2"><input type="email" id="email"
placeholder="Email*"></td>
</tr>
<tr>
<td colspan="2"><input type="url" id="link" placeholder="Website Link/
online listing link"></td>
</tr>
<tr>
<td><input type="text" id="noOfOutlets" min="1" placeholder="Number of
outlets*" required></td>
<td class="a"><input type="text" id="primaryArea" placeholder="Primary
Area of outlet*" required></td>
</tr>
<tr>
<td><input type="text" min="200" id="cost" placeholder="Minimum
purchase cost*" required></td>
<td class="a"><input list="establishmentType" id="type"
placeholder="Establishment : Independant/Chain*"
required>
<datalist id="establishmentType">
<option value="Independant"></option>
<option value="Chain"></option>
</datalist>
</td>
</tr>
<tr>
<td colspan="2">Medicines available :
<input type="checkbox" id="gsl" name="items">General Sales List
Medicines(GSL)
<input type="checkbox" id="p" name="items">Pharmacy
Medicines(P)<br>
<input type="checkbox" id="pom" name="items">Prescription Only
Medicines (POM)
<input type="checkbox" id="cds" name="items">Controlled Drugs (CDs)
</td>
</tr>
<tr>
<td>Retail Drug License(Jpeg/PDF)*<br>
<input type="file" id="license"></td>
<td>GSTIN/PAN*<br>
<input type="file" id="pan"></td>
</tr>
<tr>
<td>FSSAI(Jpeg/PDF)*<br>
<input type="file" id="fssai"></td>
<td>Facade/Pharmacy-shelves/Refridgerator(Jpeg)* <br>
<input type="file" id="others" multiple></td>
</tr>
</table>
<p class="b"><input type="checkbox"><a href="#submit" id="terms_ref"
style="color: blue;"><b>I agree to terms of
services</b></a></p>
<p class="b"><input type="button" id="submit" value="submit"></p>
</body>
</html>
