<!DOCTYPE html>
<html>
<head>
<title>Birth Certificate Manual</title>
<style>
body {
font-family: Arial, sans-serif;
margin: 20px;
}
form {
width: 50%;
margin: 40px auto;
padding: 20px;
border: 1px solid #ccc;
border-radius: 10px;
box-shadow: 0 0 10px rgba(0, 0, 0, 0.1);
}
label {
display: block;
margin-bottom: 10px;
}
input[type="text"], input[type="date"], select {
width: 100%;
height: 40px;
margin-bottom: 20px;
padding: 10px;
border: 1px solid #ccc;
}
input[type="submit"] {
width: 100%;
height: 40px;
background-color: #4CAF50;
color: #fff;
padding: 10px;
border: none;
border-radius: 10px;
cursor: pointer;
}
input[type="submit"]:hover {
background-color: #3e8e41;
}
.required {
color: red;
}
</style>
</head>
<body>
<form>
<h1>Birth certificate Manual</h1>
<label for="fullName">नाम / Full Name <span class="required">*</span></label><br>
<input type="text" id="fullName" name="fullName" placeholder="ENTER FULL NAME"><br>
<label for="aadharNumber">आधार नंबर / Aadhar Number <span class="required">*</span></label><br>
<select id="aadharNumber" name="aadharNumber">
<option value="">Please select</option>
<option value="">Null</option>
<option value="">Enter Aadhar Number</option>
</select><br>
<label for="gender">लिंग / Gender <span class="required">*</span></label><br>
<select id="gender" name="gender">
<option value="">Select Gender</option>
</select><br>
<label for="placeOfBirth">जन्म स्थान / PLACE OF BIRTH <span class="required">*</span></label><br>
<input type="text" id="placeOfBirth" name="placeOfBirth" placeholder="PLACE OF BIRTH"><br>
<label for="dateOfBirth">पान्म तिथि / DATE OF BIRTH <span class="required">*</span></label><br>
<input type="date" id="dateOfBirth" name="dateOfBirth"><br>
<label for="fatherName">पिता का नाम / Father Name <span class="required">*</span></label><br>
<input type="text" id="fatherName" name="fatherName" placeholder="FATHER'S NAME"><br>
<label for="fatherAadhar">पिता का आधार / Father Aadhar <span class="required">*</span></label><br>
<select id="fatherAadhar" name="fatherAadhar">
<option value="">Please select</option>
<option value="">Null</option>
<option value="">Enter Aadhar Number</option>
</select><br>
<label for="motherName">माता का नाम / Mother Name <span class="required">*</span></label><br>
<input type="text" id="motherName" name="motherName" placeholder="MOTHER'S NAME"><br>
<label for="motherAadhar">माता का नाम / Mother Aadhar <span class="required">*</span></label><br>
<select id="motherAadhar" name="motherAadhar">
<option value="">Please select</option>
<option value="">Null</option>
<option value="">Enter Aadhar Number</option>
</select><br>
<label for="permanentAddress">स्थायी पता / Permanent Address <span class="required">*</span></label><br>
<input type="text" id="permanentAddress" name="permanentAddress" placeholder="PERMANENT ADDRESS"><br>
<label for="addressAtBirth">जन्म के समय पता / Address at time of Birth <span class="required">*</span></label><br>
<input type="text" id="addressAtBirth" name="addressAtBirth" placeholder="ADDRESS OF BIRTH"><br>
<label for="dateOfRegistration">पंजीकरण की तिथि / Date of Registration <span class="required">*</span></label><br>
<input type="date" id="dateOfRegistration" name="dateOfRegistration"><br>
<label for="hospital">Hospital <span class="required">*</span></label><br>
<select id="hospital" name="hospital">
<option value="">Select Hospital</option>
</select><br>
<label for="state">Select State <span class="required">*</span></label><br>
<select id="state" name="state">
<option value="">Select State</option>
<option value="">Andhra Pradesh</option>
<option value="">Arunachal Pradesh</option>
<option value="">Assam</option>
<option value="">Bihar</option>
<option value="">Chandigarh</option>
<option value="">Chattisgarh</option>
<option value="">Delhi</option>
<option value="">Gujarat</option>
<option value="">Haryana</option>
<option value="">Himachal Pradesh</option>
<option value="">Jammu and Kashmir</option>
<option value="">Jharkhand</option>
<option value="">Karnataka</option>
<option value="">Kerala</option>
<option value="">Madhya Pradesh</option>
<option value="">Maharashtra</option>
<option value="">Manipur</option>
<option value="">Meghalaya</option>
<option value="">Orissa</option>
<option value="">Puducherry</option>
<option value="">Punjab</option>
<option value="">Rajasthan</option>
<option value="">Tamil Nadu</option>
<option value="">Telangana</option>
<option value="">Tripura</option>
<option value="">Uttar Pradesh</option>
<option value="">Uttarakhand</option>
<option value="">West Bengal</option>
</select><br>
<input type="submit" value="SUBMIT">
</form>