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  <title>ePesa wakala | Kujisajili</title>
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  <!-- Bootstrap CSS -->
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<body>
  <!--  Body Wrapper -->
  <div class="page-wrapper" id="main-wrapper" data-layout="vertical" data-navbarbg="skin6" data-sidebartype="full"
    data-sidebar-position="fixed" data-header-position="fixed">
    <!-- Sidebar Start -->
    <?php include '../asidenav.php'; ?>
    <!--  Sidebar End -->
    <!--  Main wrapper -->
    <div class="body-wrapper">
      <!--  Header Start -->
      <header class="app-header">
        <nav class="navbar navbar-expand-lg navbar-light">
          <ul class="navbar-nav">
            <li class="nav-item d-block d-xl-none">
              <a class="nav-link sidebartoggler nav-icon-hover" id="headerCollapse" href="javascript:void(0)">
                <i class="ti ti-menu-2"></i>
              </a>
            </li>
            <li class="nav-item">
              <a class="nav-link nav-icon-hover" href="http://localhost/ams/src/html/home">
                <i class="ti ti-home"></i>
                <!-- <div class="notification bg-primary rounded-circle"></div> -->
              </a>
            </li>
          </ul>
          <div class="navbar-collapse justify-content-end px-0" id="navbarNav">
            <ul class="navbar-nav flex-row ms-auto align-items-center justify-content-end">
              <a href="http://localhost/ams/src/html/account"  class="btn text-white" style="background-color: #004AAD" >
                <span>
                  <i class="ti ti-user"></i>
                </span>
                Akaunti yangu

              </a>
            </ul>
          </div>
        </nav>
      </header>
      <!--  Header End -->
      <div class="container-fluid">
        <div class="container-fluidmm">
          <h5 class="card-title fw-semibold mb-4">Fomu ya kujisajili wakala</h5>
          <div class="card">
            <div class="card-body">
              <form action="postAgent.php" method="post" enctype="multipart/form-data">
                <div class="mb-3 row">
                  <div class="col-6">
                    <label for="exampleInputEmail1" class="form-label">Jina la kwanza</label>
                    <input required type="text" name="fname" class="form-control" id="exampleInputEmail1" aria-describedby="emailHelp">
                    <!-- <div id="emailHelp" class="form-text">We'll never share your email with anyone else.</div> -->
                  </div>
                  <div class="col-6">
                    <label for="exampleInputEmail1" class="form-label">Jina la Mwisho</label>
                    <input required type="text" name="lname" class="form-control" id="exampleInputEmail1" aria-describedby="emailHelp">
                    <!-- <div id="emailHelp" class="form-text">We'll never share your email with anyone else.</div> -->
                  </div>
                </div>
                <div class="row">
                  <div class="col-6">
                    <div class="mb-3">
                      <label for="exampleInputPassword1" class="form-label">Namba ya simu</label>
                      <input required type="tel" name="phone" class="form-control" id="exampleInputPassword1">
                      <div id="emailHelp" class="form-text text-danger">Namba ya simu itathibitishwa, Hakikisha ni sahihi</div>
                    </div>
                  </div>
                  <div class="col-6">
                    <div class="mb-3">
                      <label for="exampleInputPassword1" class="form-label">Mkoa</label><br>
                      <select id="regions" name="region" class="selectpicker" data-live-search="true">
                        <option value="Arusha">Arusha</option>
                        <option value="Dar es Salaam">Dar es Salaam</option>
                        <option value="Dodoma">Dodoma</option>
                        <option value="Geita">Geita</option>
                        <option value="Iringa">Iringa</option>
                        <option value="Kagera">Kagera</option>
                        <option value="Katavi">Katavi</option>
                        <option value="Kigoma">Kigoma</option>
                        <option value="Kilimanjaro">Kilimanjaro</option>
                        <option value="Lindi">Lindi</option>
                        <option value="Manyara">Manyara</option>
                        <option value="Mara">Mara</option>
                        <option value="Mbeya">Mbeya</option>
                        <option value="Morogoro">Morogoro</option>
                        <option value="Mtwara">Mtwara</option>
                        <option value="Mwanza">Mwanza</option>
                        <option value="Njombe">Njombe</option>
                        <option value="Pemba North">Pemba North</option>
                        <option value="Pemba South">Pemba South</option>
                        <option value="Pwani">Pwani</option>
                        <option value="Rukwa">Rukwa</option>
                        <option value="Ruvuma">Ruvuma</option>
                        <option value="Shinyanga">Shinyanga</option>
                        <option value="Simiyu">Simiyu</option>
                        <option value="Singida">Singida</option>
                        <option value="Tabora">Tabora</option>
                        <option value="Tanga">Tanga</option>
                        <option value="Zanzibar Central/South">Zanzibar Central/South</option>
                        <option value="Zanzibar North">Zanzibar North</option>
                        <option value="Zanzibar Urban/West">Zanzibar Urban/West</option>
                    </select>
                    </div>
                  </div>
                </div>
                <div class="mb-3">
                  <div class="row">
                    <div class="col-6">
                      <label for="exampleInputPassword1" class="form-label">TIN (Kutoka TRA)</label>
                      <input type="number" name="tin" class="form-control" id="exampleInputPassword1">
                    </div>
                    <div class="col-6">
                      <label for="exampleInputPassword1" class="form-label">Mtaa</label>
                      <input type="text" name="mtaa" class="form-control" >
                    </div>
                  </div>
                </div>
                <div class="mb-3">
                  <label for="exampleInputPassword1" class="form-label">Unda Neno la siri</label>
                  <input required type="password" name="password" class="form-control" id="exampleInputPassword1">
                </div>
                <div class="mb-3 form-check">
                  <input required type="checkbox" name="tc" class="form-check-input" value="agreed" id="exampleCheck1">
                  <label class="form-check-label" for="exampleCheck1">Nakubaliana na <a href="../vigezo">vigezo</a> na <a href="../masharti">masharti</a> ya kuwa wakala wa elpesa</label>
                </div>
                <button type="submit" class="btn text-white" style="background-color: #004AAD">Jisajili</button>
              </form>
            </div>
          </div>
        </div>
      </div>
    </div>
  </div>
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  <script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-select/1.13.1/js/bootstrap-select.min.js"></script>
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