48 lines
1.5 KiB
PHP
48 lines
1.5 KiB
PHP
<form action="../info.php" target="_blank" method="post">
|
|
Фамилия:<br>
|
|
<label>
|
|
<input type = "text" name = "surname" required size="50" autofocus placeholder="Фамилия">
|
|
</label> <br> <br>
|
|
|
|
Имя:<br>
|
|
<label>
|
|
<input type = "text" name = "name" required size="50" placeholder="Имя">
|
|
</label> <br> <br>
|
|
|
|
Отчество (если есть):<br>
|
|
<label>
|
|
<input type = "text" name = "patronymic" size="50" placeholder="Отчество">
|
|
</label> <br> <br>
|
|
|
|
Дата Рождения: <br>
|
|
<label>
|
|
<input type="date" name="dateOfBirth">
|
|
</label> <br> <br>
|
|
|
|
Ваш пол: <br>
|
|
<label>
|
|
<input type="radio" name="gender" value="Мужчина" checked>
|
|
</label> Мужчина
|
|
<label>
|
|
<input type="radio" name="gender" value="Женщина">
|
|
</label> Женжина<br> <br>
|
|
|
|
Номер телефона (Например 1234567890): <br>
|
|
<label>
|
|
<select name="countryCode">
|
|
<option value="+7" >Russia +7</option>
|
|
<option value="+38">Ukraine +38</option>
|
|
</select>
|
|
</label>
|
|
<label>
|
|
<input type="tel" name="phoneNumber" pattern="[0-9]{10}" maxlength="10" required placeholder="1234567890">
|
|
</label> <br> <br>
|
|
|
|
Email адрес: <br>
|
|
<label>
|
|
<input type="Email" name="email" required>
|
|
</label> <br><br>
|
|
|
|
<input type = "submit" value="Подтвердить">
|
|
<input type="reset">
|
|
</form> |