<div class="bg-gray-100 py-10"> <div class="max-w-5xl mx-auto px-6"> <div class="bg-white shadow rounded-lg p-6"> <h1 class="text-2xl font-semibold text-gray-900 mb-6">Become a Car Service History Affiliate</h1> <form method="POST" action="https://carservicehistory.co.uk/affiliate/register" class="space-y-6"> <input type="hidden" name="_token" value="gRQti4ghdAFbdBCWg709ADLNy5SQq6vyRp6idyK6" autocomplete="off"> <div> <label for="name" class="block text-sm font-medium text-gray-700">Full name</label> <input id="name" name="name" type="text" value="" required class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" /> </div> <div> <label for="email" class="block text-sm font-medium text-gray-700">Email address</label> <input id="email" name="email" type="email" value="" required class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" /> </div> <div class="grid grid-cols-1 gap-6 md:grid-cols-2"> <div> <label for="password" class="block text-sm font-medium text-gray-700">Password</label> <input id="password" name="password" type="password" required class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" /> </div> <div> <label for="password_confirmation" class="block text-sm font-medium text-gray-700">Confirm password</label> <input id="password_confirmation" name="password_confirmation" type="password" required class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" /> </div> </div> <div> <label for="payout_method" class="block text-sm font-medium text-gray-700">Preferred payout method</label> <select id="payout_method" name="payout_method" class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500"> <option value="">Select a payout method</option> <option value="paypal" >PayPal</option> <option value="bank_transfer" >Bank transfer</option> </select> </div> <div> <label for="paypal_email" class="block text-sm font-medium text-gray-700">PayPal email (if applicable)</label> <input id="paypal_email" name="paypal_email" type="email" value="" class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" /> </div> <div> <label for="bank_details" class="block text-sm font-medium text-gray-700">Bank transfer details</label> <textarea id="bank_details" name="bank_details" rows="4" class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" placeholder="Account name, sort code, account number"></textarea> </div> <div class="flex items-center justify-between"> <a href="https://carservicehistory.co.uk/affiliate/login" class="text-sm text-indigo-600 hover:text-indigo-500"> Already an affiliate? Sign in </a> <button type="submit" class="inline-flex items-center rounded-md border border-transparent bg-indigo-600 px-4 py-2 text-sm font-medium text-white shadow-sm hover:bg-indigo-700 focus:outline-none focus:ring-2 focus:ring-indigo-500 focus:ring-offset-2"> Create affiliate account </button> </div> </form> </div> </div> </div>