<%@ CodePage = 1256 %> <head> <meta http-equiv="Content-Language" content="en-us"> <meta http-equiv="Content-Type" content="text/html; charset=windows-1252"> <meta name="GENERATOR" content="Microsoft FrontPage 4.0"> <meta name="ProgId" content="FrontPage.Editor.Document"> <title>GDRFA-D eServices</title> <style> .tborder{ border: 1px solid #90BDF3; } .tborder1{ border: 1px solid #CECECE; } .style1 { font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 12px; font-weight: bold; color: #000000; } .style2 { font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; color: #000000; } .style4 { font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; font-weight: bold; color: #000000; } INPUT, TITLE, SELECT, TEXTAREA,LABEL,TEXT { color: black; font-family: verdana; font-size:11px; border-width:1px; border-style:solid; border-color:#7EB0C9; } .chb{ border:none } .style3 { font-family: "Times New Roman", Times, serif; font-size: 10px; color: #000000; } .style6 { font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; color: #FF0000; } .style7 { font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; color: #FF0000; } .style8 { font-family: Verdana, Arial, Helvetica, sans-serif; font-weight:bold; font-size: 10px; color: #FF0000; } </style> <script language=JavaScript> <!-- function check_length(my_form) { maxLen = 240; // max number of characters allowed if (PrintForm.my_text.value.length >= maxLen) { // Alert message if maximum limit is reached. // If required Alert can be removed. var msg = "You have reached your maximum limit of characters allowed"; alert(msg); // Reached the Maximum length so trim the textarea PrintForm.my_text.value = PrintForm.my_text.value.substring(0, maxLen); } } //--> </script> </head> <body leftmargin="0" topmargin="0" onFocus="PrintForm.PrintForma.style.visibility = 'visible';PrintForm.re.style.visibility = 'visible'" > <form name=PrintForm method=post> <table width="90%" border="0" cellspacing="0" cellpadding="0" align="center" class="tborder" > <tr> <td width="10%" align="center" style="padding-left: 5px" height="73"><img src="datel.gif" width="120" height="41" /></td> <td width="80%" align="center" height="73"><img src="eservice_03.gif" alt="eServices" width="201" height="32" /></td> <td width="10%" align="center" height="73"><img src="dnrd.gif" alt="GDRFA-D" width="65" height="71" /></td> </tr> <tr> <td colspan="3" height="5" bgcolor="#CECECE"></td> </tr> <tr> <td colspan="3" height="20" align="center"><span class="style1">Please Choose Which Service You Need</span></td> </tr> <tr> <td colspan="3" height="1" bgcolor="#333333"></td> </tr> <tr> <td colspan="3" valign="top"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr><td colspan="6" height="3"></td> </tr> <tr> <td width="142" align="right" style="padding-left:15px"><span class="style2">Activation :&nbsp;</span></td> <td width="98" align="left"><input type="checkbox" name="checkbox" value="checkbox" class="chb"></td> <td width="190" align="right"><span class="style2">Adding Companies :&nbsp;</span></td> <td width="113" align="left"><input type="checkbox" name="checkbox2" value="checkbox" class="chb"></td> <td width="215" align="right"><span class="style2">Balance Transferring :&nbsp;</span></td> <td width="134" align="left"><input type="checkbox" name="checkbox3" value="checkbox" class="chb"></td> </tr> <tr><td colspan="6" height="2"></td> </tr> </table> </td></tr> <tr> <td colspan="3" bgcolor="#E0DEDE" height="180"> <table width="100%" border="0" cellspacing="0" cellpadding="0" height="223"> <tr><td colspan = "3" height= 1></td></tr> <tr> <td width="33%" align="right" height="25"><span class="style2">Request Date :&nbsp;</span></td> <td width="34%" height="25"><input name="reqdate" type="text" size="50" maxlength="50"/> </td> <td width="33%" height="25" ><span class="style3">&nbsp;:&nbsp&#1578;&#1575;&#1585;&#1610;&#1582; &#1575;&#1604;&#1591;&#1604;&#1576; </span></td> </tr> <tr> <td align="right" height="25"><span class="style2">Sponsor No# :&nbsp;</span></td> <td height="25"><input name="spnno" type="text" size="50" maxlength="100"/></td> <td height="25"><span class="style3">&nbsp;: &#1585;&#1602;&#1605; &#1575;&#1604;&#1605;&#1606;&#1588;&#1571;&#1577; </span></td> </tr> <tr> <td align="right" height="51" valign="top"><span class="style2">Company Name :&nbsp;</span></td> <td height="51"><textarea onKeyPress=check_length(this.form); name=my_text rows=6 cols=52 style="overflow:hidden" ></textarea></td> <td height="51" valign="top"><span class="style3">&nbsp;: &#1575;&#1587;&#1605; &#1575;&#1604;&#1588;&#1585;&#1603;&#1577; </span></td> </tr> <tr> <td align="right" height="25"><span class="style2">User Name :&nbsp;</span></td> <td height="25"><input name="uname" type="text" size="50" maxlength="100"/></td> <td height="25"><span class="style3">&nbsp;: &#1575;&#1587;&#1605; &#1575;&#1604;&#1605;&#1587;&#1578;&#1582;&#1583;&#1605; </span></td> </tr> <tr> <td width="33%" align="right" height="25"><span class="style2">Acc No* ( Transfer only ) :&nbsp;</span></td> <td height="25"><input name="accno" type="text" size="50" maxlength="100"/></td> <td width="33%" height="25" ><span class="style3">&nbsp;&nbsp;:( &#1585;&#1602;&#1605; &#1575;&#1604;&#1581;&#1587;&#1575; &#1576;&nbsp;(&#1578;&#1581;&#1608;&#1610;&#1604; &#1601;&#1602;&#1591;</span></td> </tr> <tr> <td align="right" height="25"><span class="style2">Requested By :&nbsp;</span></td> <td height="25"><input name="reqby" type="text" size="50" maxlength="100"/></td> <td height="25"><span class="style3">&nbsp;: &#1578;&#1605; &#1575;&#1604;&#1578;&#1602;&#1583;&#1610;&#1605; &#1605;&#1606; &#1602;&#1576;&#1604; </span></td> </tr> <tr> <td align="right" height="25"><span class="style2">Contact No# :&nbsp;</span></td> <td height="25"><input name="cont" type="text" size="50" maxlength="100"/></td> <td height="25"><span class="style3">&nbsp;: &#1585;&#1602;&#1605; &#1575;&#1604;&#1607;&#1575;&#1578;&#1601;</span></td> </tr> <tr><td colspan = "3" height= 21></td></tr> </table> <tr><td colspan= "3" align="center" height="222"> <table border="0" width="100%"> <tr> <td width="238" valign="top" align="right"><span class="style2">Authorized Signature :&nbsp;</span></td> <td width="400" valign="bottom"><hr></td> <td width="217" valign="top" align="left"><span class="style3">&nbsp;: &#1578;&#1608;&#1602;&#1610;&#1593; &#1575;&#1604;&#1605;&#1582;&#1600;&#1600;&#1600;&#1608;&#1604;</span> </td> </tr> <tr> <td width="238" valign="top" align="right"><span class="style2">Authorized Stamp :&nbsp;</span></td> <td valign="bottom" colspan = "2" align="left"> <table border="0" height ="125" width="290" class="tborder1"> <tr> <td width="100%">&nbsp;</td> </tr> </table> </td> </tr> <tr><td colspan= "3" height="10"> <table border="0" width="86%"> <tr> <td width="21%" align="right"> </td> <td width="20%" align="left"><span class="style8">Required Documents</span></td> <td width="59%" align="left"><span class="style8">&nbsp;: &#1575;&#1604;&#1575;&#1608;&#1585;&#1575;&#1602; &#1575;&#1604;&#1605;&#1591;&#1604;&#1608;&#1576;&#1577;</span></td> </tr> <tr> <td width="17%" align="right"> </td> <td width="60%" align="left"> <span class="style6">Original P.R.O Card + Copy</span></td> <td width="10%" align="left"><span class="style7">&#1576;&#1591;&#1575;&#1602;&#1577; &#1575;&#1604;&#1605;&#1606;&#1583;&#1608;&#1576; &#1608; &#1589;&#1608;&#1585;&#1577; &#1605;&#1606;&#1607;</span></td> </tr> <tr> <td width="17%" align="right"> </td> <td width="55%" align="left"> <span class="style6">Original Establishment Card+ Copy </span></td> <td width="13%" align="left"><span class="style7">&#1576;&#1591;&#1575;&#1602;&#1577; &#1575;&#1604;&#1605;&#1606;&#1588;&#1571;&#1577; &#1608; &#1589;&#1608;&#1585;&#1577; &#1605;&#1606;&#1607;</span></td> </tr> <tr> <td width="17%" height="14" align="right"></td> <td width="55%" align="left" valign="top"><span class="style6">* The Receipt Copy</span><span class="style7"> Only For Transfer</span></td> <td width="13%" align="left"><span class="style7">&#1589;&#1608;&#1585;&#1607; &#1605;&#1606; &#1575;&#1604;&#1585;&#1589;&#1610;&#1583; &#1575;&#1604;&#1605;&#1575;&#1604;&#1610;*</span></td> </tr> </table> <td width="0"> </tr> </table><td height="222" width="1"> <tr> <td colspan="3" height="21"><hr noshade size="1"></td> </tr> <tr> <td colspan="3" height="14" > <span class="style4">&nbsp;&nbsp; &nbsp;For GDRFA-D Internal Use Only</span></td> </tr> <tr> <td colspan="3" align="center" height="168"> <table border="0" width="100%"tborder" cellspacing = "0" cellpadding = "0" bgcolor="#cecece"> <tr><td colspan="3" height="10"></td></tr> <tr> <td width="12%" >&nbsp;</td> <td width="15%" ><span class="style2">&nbsp;Completed By :</span></td> <td width="74%" valign="bottom" align="left"><hr noshade size="1" width="300"></td> </tr> <tr><td colspan="3" height="10"></td></tr> <tr> <td><span class="style2">&nbsp;</span></td> <td valign="top"><span class="style2">&nbsp;Comments :</span></td> <td height="150"></td> </tr> <tr> <td align="center"> </td> <td align="center">&nbsp;</td> <td align="left"></td> </tr> <tr> <td colspan="3" align="center"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="11%" align="right" valign="top"><span class="style2">&nbsp;Date :</span></td> <td width="35%" valign="bottom"><hr></td> <td width="22%" align="right" valign="top"<span class="style2">&nbsp;Signature :</span></td> <td width="34%" valign="bottom"><hr></td> </tr> </table> </td> </tr> <tr> <td colspan="3" height="8"> </td> </tr> </table> </td> </tr> <tr> <td height="15" colspan="2" align="center"> </td> <tr> <td height="21" colspan="2" align="center"> <input name="PrintForma" type="button" onClick="this.style.visibility = 'hidden'; re.style.visibility = 'hidden'; window.print();this.style.visibity = 'inherit';re.style.visibity = 'inherit';" value="Print"> <input type="Reset" name="re" value="Reset"></td> </tr> <tr> <td height="15" colspan="2" align="center"> </td> </tr> </table> </form> </body>