354 lines
18 KiB
JavaScript
354 lines
18 KiB
JavaScript
const ElectricityActForm = (props) => {
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const { caseReference } = props;
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return (
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<>
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<div class="govuk-grid-row">
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<div class="govuk-grid-column-two-thirds">
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<h1 class="govuk-heading-m govuk-!-margin-top-5">
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Enter your appeal information
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</h1>
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<form>
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<div class="govuk-grid-column-full">
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<div class="govuk-grid-row">
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<div class="govuk-form-group">
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<label
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class="govuk-label "
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for="pinswg_name"
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>
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Name
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</label>
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<input
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type="text"
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name="pinswg_name"
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id="pinswg_name"
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component="[object Object]"
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class="govuk-input govuk-input--width-20"
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disabled
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value="CAS-00497-K4H2Z5"
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_anticipatedgridreferencenorthingtext"
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id="pinswg_anticipatedgridreferencenorthingtext_label"
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>
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Anticipated Grid Reference Northing
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_anticipatedgridreferencenorthingtext"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_anticipatedgridreferenceeastingtext"
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id="pinswg_anticipatedgridreferenceeastingtext_label"
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>
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Anticipated Grid Reference Easting
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_anticipatedgridreferenceeastingtext"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_projectname"
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id="pinswg_projectname_label"
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>
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Project Name
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_projectname"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_projectdiscription"
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id="pinswg_projectdiscription_label"
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>
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Project Discription
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_projectdiscription"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_projectlocation"
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id="pinswg_projectlocation_label"
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>
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Project Location
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_projectlocation"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_addresscounty"
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id="pinswg_addresscounty_label"
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>
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Address County
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_addresscounty"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_addressline1"
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id="pinswg_addressline1_label"
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>
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Address Line 1
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_addressline1"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_addressline2"
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id="pinswg_addressline2_label"
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>
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Address Line 2
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_addressline2"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_addresstown"
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id="pinswg_addresstown_label"
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>
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Address Town
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_addresstown"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_postcode"
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id="pinswg_postcode_label"
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>
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Post Code
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_postcode"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_agentcontactname"
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id="pinswg_agentcontactname_label"
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>
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Agent Contact Name
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_agentcontactname"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_emailaddress"
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id="pinswg_emailaddress_label"
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>
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Email Address
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_emailaddress"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_salutation"
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id="pinswg_salutation_label"
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>
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Salutation
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_salutation"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_firstname"
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id="pinswg_firstname_label"
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>
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First Name
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_firstname"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_lastname"
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id="pinswg_lastname_label"
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>
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Last Name
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_lastname"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_organisation"
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id="pinswg_organisation_label"
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>
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Organisation
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_organisation"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_role"
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id="pinswg_role_label"
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>
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Role
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_role"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_telephonenumber"
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id="pinswg_telephonenumber_label"
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>
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Telephone Number
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_telephonenumber"
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value=""
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/>
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</div>
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</div>
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<div class="govuk-grid-row">
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<div class="govuk-form-group ">
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<label
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class="govuk-label "
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for="pinswg_webaddress"
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id="pinswg_webaddress_label"
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>
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Web Address
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</label>
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<input
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class="govuk-input govuk-input--width-20"
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id="pinswg_webaddress"
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value=""
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/>
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</div>
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</div>
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</div>
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<div class="govuk-button-group">
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<button
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type="submit"
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class="govuk-button"
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data-module="govuk-button"
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>
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Submit
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</button>
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</div>
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</form>
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</div>
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</div>
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</>
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);
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};
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export default ElectricityActForm;
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