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< ? php include_once 'header.php' ; ?>
< div class = " row " >
< div id = " content " class = " col-xs-12 col-sm-8 " >
< h1 > Registrarse </ h1 >
< form id = " registerform " action = " register.php " method = " post " class = " form-horizontal " >
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< fieldset disabled = " disabled " >
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< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " txtnombre " > Nombre :</ label >
< div class = " col-sm-8 " >
< input id = " txtnombre " class = " form-control " name = " nombre "
placeholder = " Juan " type = " text " pattern = " ^[a-zA-Z][a-zA-Z \ s \ -.'`áéíóú]*[a-zA-Z] $ " required >
</ div >
</ div >
< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " txtapellido " > Apellido :</ label >
< div class = " col-sm-8 " >
< input id = " txtapellido " class = " form-control " name = " apellido "
placeholder = " Perez " type = " text " pattern = " ^[a-zA-Z][a-zA-Z \ s \ -.'`áéíóú]*[a-zA-Z] $ " required >
</ div >
</ div >
<!-- Selector de Documento mas nro -->
< div class = " form-group row " >
< label class = " col-sm-2 control-label " for = " txtdocnro " > Documento :</ label >
< div class = " col-sm-8 " >
< div class = " input-group " >
< div class = " input-group-btn " >
< button id = " btntipodoc " type = " button " class = " btn btn-default dropdown-toggle " data - toggle = " dropdown " aria - haspopup = " true " aria - expanded = " false " > Tipo < span class = " caret " ></ span ></ button >
< ul id = " tipodoc " class = " dropdown-menu " >
< li >< a href = " # " > C . I .</ a ></ li >
< li >< a href = " # " > Otro </ a ></ li >
</ ul >
< input id = " txttipodoc " name = " doctype " type = " hidden " >
</ div ><!-- / btn - group -->
< input id = " txtdocnro " name = " docnro " class = " form-control "
placeholder = " Seleccione Tipo de Documento... " type = " text " required >
</ div ><!-- / input - group -->
</ div >
</ div >
< div class = " form-group row " >
< label class = " col-sm-2 control-label " for = " txtdir " > Pais :</ label >
< div class = " col-sm-2 " >
< button id = " btnpais " type = " button " class = " btn btn-default dropdown-toggle " data - toggle = " dropdown " aria - haspopup = " true " aria - expanded = " false " > Pais < span class = " caret " ></ span ></ button >
< ul id = " lstpais " class = " dropdown-menu " >
< li >< a href = " # " > Uruguay </ a ></ li >
< li >< a href = " # " > Alemania </ a ></ li >
< li >< a href = " # " > Austria </ a ></ li >
< li >< a href = " # " > Argentina </ a ></ li >
< li >< a href = " # " > Bolivia </ a ></ li >
< li >< a href = " # " > Brasil </ a ></ li >
< li >< a href = " # " > Canadá </ a ></ li >
< li >< a href = " # " > Chile </ a ></ li >
< li >< a href = " # " > Colombia </ a ></ li >
< li >< a href = " # " > Ecuador </ a ></ li >
< li >< a href = " # " > España </ a ></ li >
< li >< a href = " # " > Estados Unidos </ a ></ li >
< li >< a href = " # " > Francia </ a ></ li >
< li >< a href = " # " > Inglaterra </ a ></ li >
< li >< a href = " # " > Italia </ a ></ li >
< li >< a href = " # " > México </ a ></ li >
< li >< a href = " # " > Paraguay </ a ></ li >
< li >< a href = " # " > Perú </ a ></ li >
< li >< a href = " # " > Suiza </ a ></ li >
< li >< a href = " # " > Venezuela </ a ></ li >
< li >< a href = " # " > Otro </ a ></ li >
</ ul >
< input id = " txtpais " name = " pais " type = " hidden " >
</ div >
< label class = " col-sm-2 control-label " for = " txtciudad " > Ciudad :</ label >
< div class = " col-sm-4 " >
< input id = " txtciudad " name = " ciudad " class = " form-control "
placeholder = " Montevideo " type = " text " required >
</ div >
</ div >
< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " txtdir " > Dirección :</ label >
< div class = " col-sm-8 " >
< input id = " txtdir " class = " form-control " name = " dir "
placeholder = " 18 de Julio 1432 apto 302 " type = " text " required >
</ div >
</ div >
< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " txttel " > Teléfono :</ label >
< div class = " col-sm-8 " >
< input id = " txttel " class = " form-control " name = " tel "
placeholder = " 099123456 " type = " text " required >
</ div >
</ div >
< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " txtmail " > Email :</ label >
< div class = " col-sm-8 " >
< input id = " txtmail " class = " form-control " name = " email "
placeholder = " mail@example.com " type = " email " required >
</ div >
</ div >
< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " txtprof " > Profesión :</ label >
< div class = " col-sm-8 " >
< input id = " txtprof " class = " form-control " name = " profesion "
placeholder = " Profesor, Docente o Estudiante, etc " type = " text " pattern = " [a-zA-Z]* " required >
</ div >
</ div >
< div class = " form-group row " >
< label class = " col-sm-2 control-label " for = " btntrabaja " > Sector :</ label >
< div class = " col-sm-8 " >
< button id = " btntrabaja " type = " button " class = " btn btn-default dropdown-toggle " data - toggle = " dropdown " aria - haspopup = " true " aria - expanded = " false " > Seleccione < span class = " caret " ></ span ></ button >
< ul id = " lsttrabaja " class = " dropdown-menu " >
< li >< a href = " # " > Primaria </ a ></ li >
< li >< a href = " # " > Secundaria </ a ></ li >
< li >< a href = " # " > Universidad </ a ></ li >
< li >< a href = " # " > UTU </ a ></ li >
< li >< a href = " # " > UTEC </ a ></ li >
< li >< a href = " # " > IPA / CERP </ a ></ li >
< li >< a href = " # " > Otros Privado </ a ></ li >
< li >< a href = " # " > Otros Público </ a ></ li >
</ ul >
< input id = " txttrabaja " name = " trabaja " type = " hidden " >
</ div >
</ div >
< div class = " form-group " >
< label class = " control-label col-sm-2 " for = " sifinan " > ¿Necesita financiación ? </ label >
< div class = " col-sm-8 " >
< label class = " radio-inline " >< input id = " sifinan " type = " radio " name = " financiacion " value = " si " > Sí </ label >
< label class = " radio-inline " >< input id = " nofinan " type = " radio " name = " financiacion " value = " no " > No </ label >
</ div >
</ div >
< div id = " detallefinan " class = " form-group " >
< label class = " control-label col-sm-2 " for = " txtfinan " > Detalle estimación de costo :</ label >
< div class = " col-sm-8 " >
< textarea id = " txtfinan " class = " form-control " name = " detallefinan " rows = " 10 " style = " height:200px; " placeholder = " Haga una breve aclaración de la solicitud incluyendo costos estimados " >
</ textarea >
</ div >
</ div >
< div class = " form-group " >
< div class = " g-recaptcha col-sm-8 col-sm-offset-2 " data - sitekey = " 6LeLxy4UAAAAALcrNXxcOiW1B3QgcfgZ6u4l52kZ " data - callback = " onReturnCallback " ></ div >
</ div >
< div class = " form-group " >
< div class = " col-sm-8 col-sm-offset-2 " >
< button type = " submit " class = " btn-lg btn btn-primary " > Registrar </ button >
</ div >
</ div >
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</ fieldset >
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</ form >
< p class = " text-danger " >
< strong >*</ strong > si por alguna razón necesita registrarse nuevamente , llene el formulario de nuevo y se tendrá en cuenta el último de los registros .
</ p >
< div id = " statusmsg " class = " alert alert-success " >
< strong > Success !</ strong > Indicates a successful or positive action .
</ div >
<!--< div id = " myModal " class = " modal fade " role = " dialog " >
< div class = " modal-dialog " >
<!-- Modal content -->
<!--< div class = " modal-content " >
< div class = " modal-header " >
< button type = " button " class = " close " data - dismiss = " modal " >& times ; </ button >
< h4 class = " modal-title " > Revise sus datos cuidadosamente y confirme </ h4 >
</ div >
< div class = " modal-body " >
< p > Some text in the modal .</ p >
</ div >
< div class = " modal-footer " >
< button type = " button " class = " btn btn-default " data - dismiss = " modal " > Sí
</ button >
< button type = " button " class = " btn btn-default " data - dismiss = " modal " > No
</ button >
</ div >
</ div >
</ div >
</ div >-->
</ div >
< ? php include_once 'sidebar.php' ; ?>
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< ? php include_once 'footer.php' ; ?>