<div class="form-group bg-light">
   <div class="row text-center">
        <img src="images/logo.png" class="p-3 text-center">
  <div class="pull-left">
    <small>
     <h2 class="h5"><strong>GOVERNMENT OF EBONYI STATE OF NIGERIA</strong></h2>
     <h4><small>Land Use (Grant of Right of Occupancy) Regulation, 1979</small></h4>
      <h3 class="h5"><strong>LAND ALLOCATION/APPLICATION <br>FOR STATUTORY RIGHT OF OCCUPANCY</strong></h3>
     </small>
    </div>
 </div>
<form action="">

 <div class="form-group col">
   <label for="app_fullname">
        <b>Applicant's Name(in Full)</b>
 </label>
     <input type="text" class="form-control form-input" name="fullname" placeholder="Full Name">
  </div>

<div class="form-group col">
      <label for="app_DOB">
         <b>Applicant's Age and Date of Birth</b>
      </label>
  
    <input type="text" class="form-control form-input" name="Age" placeholder="Age">
 
      <input type="text" class="form-control form-input" name="DOB" placeholder="Date of Birth">
 </div>


 <div class="form-group col">
     <label for="app_nationality" class="col">
         <b>Nationality</b>
      </label>
   
        <select name="nationality" id="" class="form-control">
        <option value="">......Select Nationality.........</option>
        <option value="Nigerian">Nigerian</option>
        <option value="Others">Others</option>
        </select>
</div>
  
    <br> <br>


  <div class="form-group col">
     <label for="app_resi_address">
         <b>Residential Address</b>
     </label>
       
         <input type="text" class="form-control" name="app_resi_address" placeholder="Residential Address">
   </div>
   
  
   <div class="form-group col">
      <label for="app_postal_address">
                <b>Postal Address</b>
        </label>
      
                <input type="text" class="form-control form-input" name="app_postal_address" placeholder="Postal Address">
   </div>

 <div class="form-group col">
    <label for="app_LGA_origin">
                <b>Local Government Area of Origin</b>
    </label>
  
        <select name="app_LGA_origin" id="" class="form-control select-lg">
           <option value="">Select Local Government Area of Origin</option>
           <option value="">LGA 1</option>
           <option value="Others">LGA</option>
        </select>    
 </div>

  <div class="form-group col pt-2">
      <label for="app_autono_community">
            <b>Autonomous Community</b>
      </label>

     <input type="text" class="form-control" name="apapp_autono_communityp" placeholder="Autonomous Community">
   </div>

 <div class="form-group col">
      <label for="app_occupation">
               <b>Occupation</b>
      </label>
  
      <span><small>Length of Service (if employed)</small>
      <input type="text" class="form-control form-input" name="app_occupation_A" placeholder="Occupation">
      </span>
      <span><small>Salary Level (if employed)</small></span>
     <input type="text" class="form-control form-input" name="app_occupation_B" placeholder="Occupation">
   </div>


 <div class="form-group col">
  <label for="app_annual_inco">
      <b>Annual Income</b>
  </label>
 
     <input type="text" class="form-control form-input" name="app_annual_inco" placeholder="Annual Income">
   </div>
<div class="form-group col">
  <label for="app_office_held">
      <b>Public Office Held <span>(Past and Present)</span></b>
  </label>

     <input type="text" class="form-control form-input" name="app_office_held" placeholder="Public Office Held">
   </div>

<div class="form-group col">
  <label for="app_national_honour">
      <b>National Honours</b>
  </label>
  
     <input type="text" class="form-control form-input" name="app_national_honour" placeholder="National Honours">
   </div>
<div class="form-group col">
  <label for="app_office_held">
      <b>Tax Clearance Certificate Nos</b>
  </label>
  
     <small> <span>Or three years tax reciepts(attach Photocopies)</span></small>
     <input type="text" class="form-control form-input" name="app_tax_clearance_cert_nos" placeholder="Tax Clearance Certificate Nos">
   </div>
<div class="form-group col">
  <label for="app_town_and_layout">
      <b>Town and Layout applied for</b>
  </label>
  
     <input type="text" class="form-control form-input" name="app_town_and_layout" placeholder="Town and Layout applied for">
   </div>
 <div class="form-group col">
  <label for="app_land_purpose">
      <b>Purpose for which the land is required</b>
  </label>
     <input type="text" class="form-control form-input" name="app_land_purpose" placeholder="Purpose for which the land is required">  <small> <span>(Residential, Industrial, Residential/Commercial</span> </small>
   </div>


<div class="pt-2 bg-light">
  <h4 class="text-center">
    <b>SECTION B -FOR COMPANIES AND ORGANISATIONS</b>      
  </h4>
  <p class="text-center">Where applicable</p>
 <div class="form-group col">
  <label for="app_company_name">
      <b>Name of Company or Organisation</b>
  </label>
 
     <input type="text" class="form-control form-input" name="app_company_name" placeholder="Name of Company or Organisation">
   </div>
</div>

<div class="form-group col">
  <label for="app_company_name">
      <b>Incorporation Registration No of company or Organization</b>
  </label>
  
        <span><small>(attach Photocopy of Certificate)</small></span>
     <input type="text" class="form-control form-input" name="app_company_name" placeholder="Name of Company or Organisation">
   </div>
   <div class="btn-group justify-center col">
      <!-- <div class="pull-right"> -->
       <input type="submit" name="frmLandalloc" class="btn btn-secondary btn-lg m-2 text-center" value="Apply" style="width:20em;">
      <a href="#">
          <!-- Download Form  -->
         <br> <i class="fa fa-download fa f-2"></i>
      </a>
      <!-- </div> -->
   </div>
</div>
</div>
</form>
</div>