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荊州市第一人民醫院

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湖北省荊州市沙市區中山路商業(yè)步行街2號

0716-8237888 清廉監督電話(huà)：17362580888

103757450@qq.com

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<label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                姓名：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_FullName" data-ename="單行文本輸入框">
                        <input id="" name="item_22" data-type="1" data-subType="1"
                            class="InputText form-control" type="text"                             data-required="false"   maxlength="32"
                             placeholder="請輸入姓名" tit="姓名" />
                        <div   id="chvltdp5"   class="e_unit p_UnitName"></div>
                    </div>
                </div>
                
                
                                                                
                                                
                                <div   id="chvltdp5"   class="e_box form-group p_GenderBox" data-ename="單選信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                性別：
                    </label>
                    <div   id="chvltdp5"   class="e_box d_CustomValueBox p_CustomValueBox">
                                                                        <div data-foreachitem class="e_radio p_sex">
                            <label class="option" for="23">
                                <input id="23" class="radio-inline" type="radio" name="item_23" value="1"
                                    checked="">
                                男
                            </label>
                        </div>
                                                <div data-foreachitem class="e_radio p_sex">
                            <label class="option" for="23">
                                <input id="23" class="radio-inline" type="radio" name="item_23" value="2"
                                    checked="">
                                女
                            </label>
                        </div>
                                            </div>
                </div>
                
                
                                                                
                                                
                                <div   id="chvltdp5"   class="e_box form-group p_PhoneBox" data-ename="手機信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                手機：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_phone" data-ename="手機輸入框">
                        <input id="" name="item_24" class="InputText form-control" maxlength="20" data-type="1"
                            data-subType="3" type="text"  data-required="false"  placeholder="請輸入手機號" tit="手機">
                    </div>
                </div>
                
                
                                                                
                                                
                                <div   id="chvltdp5"   class="e_box form-group p_TelephoneBox" data-ename="電話(huà)信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                電話(huà)：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_telephone" data-ename="電話(huà)輸入框">
                        <input id="" name="item_25" class="InputText form-control" maxlength="32" data-type="1"
                            data-subType="4" type="text"  data-required="false"  placeholder="請輸入電話(huà)號碼" tit="電話(huà)">
                    </div>
                </div>
                
                
                                                                
                                                
                                <div   id="chvltdp5"   class="e_box form-group p_TelephoneBox" data-ename="電話(huà)信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                傳真：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_telephone" data-ename="電話(huà)輸入框">
                        <input id="" name="item_26" class="InputText form-control" maxlength="32" data-type="1"
                            data-subType="4" type="text"  data-required="false"  placeholder="請輸入傳真號碼" tit="傳真">
                    </div>
                </div>
                
                
                                                                
                                                
                                <div   id="chvltdp5"   class="e_box form-group p_EmailBox" data-ename="郵箱信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                郵箱：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_email" data-ename="郵箱輸入框">
                        <input id="" name="item_27" class="InputText form-control" maxlength="64" data-type="1"
                            data-subType="5" type="text"  data-required="false"  placeholder="請輸入郵箱" tit="郵箱">
                    </div>
                </div>
                
                
                                                                
                                                
                                <div data-foreachitem class="e_box form-group p_FullNameBox" data-ename="單行文本信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                地址：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_FullName" data-ename="單行文本輸入框">
                        <input id="" name="item_28" data-type="1" data-subType="1"
                            class="InputText form-control" type="text"                             data-required="false"   maxlength="255"  placeholder="請輸入地址" tit="地址" />
                        <div   id="chvltdp5"   class="e_unit p_UnitName"></div>
                    </div>
                </div>
                
                
                                                                
                                                
                                <div data-foreachitem class="e_box form-group p_FullNameBox" data-ename="單行文本信息區">
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                                                郵編：
                    </label>
                    <div   id="chvltdp5"   class="e_input p_FullName" data-ename="單行文本輸入框">
                        <input id="" name="item_29" data-type="1" data-subType="1"
                            class="InputText form-control" type="text"                             data-required="false"   maxlength="128"
                             placeholder="請輸入郵編" tit="郵編" />
                        <div   id="chvltdp5"   class="e_unit p_UnitName"></div>
                    </div>
                </div>
                
                
                                                                                                
                <div   id="chvltdp5"   class="e_box form-group p_CaptchasBox" data-ename="驗證碼">
                    
                    <label for="c_intentionIntro" class="e_title col-sm-2 control-label d_formItemTitle h5 color_normal p_intentionIntroTitle">
                        <span id="chvltdp5"    class="e_title d_formItemStar color_error p_intentionIntroStar">*</span>
                        <span id="chvltdp5"    class="i_captcha"> 驗證碼：</span>                    </label>
                    
                    
                    <div   id="chvltdp5"   class="e_box p_EntryBox" data-ename="輸入驗證碼容器">
                        
                        <div   id="chvltdp5"   class="e_input p_EntryInput" data-ename="驗證碼輸入框">
                            
                            <input name="captchas" class="InputText form-control" type="input" data-required="true" value=""
                                placeholder="請輸入驗證碼" maxlength="5" tit=" 驗證碼" data-error=" 驗證碼錯誤或已失效">
                        </div>
                        
                    </div>
                    
                    
                    <div   id="chvltdp5"   class="e_image p_image" data-ename="驗證碼圖片">
                        <img src="" width="100%" height="100%" alt="驗證碼">
                    </div>
                    
                </div>
                
                
                <div   id="chvltdp5"   class="e_wbox p_CoupWBox">
                    <button type="button" class="btn btn-primary submitPC p_submit" data-ename="提交按鈕">提交</button>
                </div>
                
                            </div>
            
        </form>
    </div>
    
        </div>
<script type="text/javascript">
    $comp({
        CorrectRequired: "請正確填寫(xiě)必填項數據！",
        DataFailed: "提交數據失??！",
        mp: " 不能為空",
        number: " 只能輸入數字",
        captchasErrorPrompt: "您輸入的驗證碼有誤，或已失效。",
        correct: " 請輸入正確的",
        correctG: " 請輸入正確格式的",
        hm: " 號碼",
        id: "portalResMessage_form-15928038620866560",
        lib: ["js/portalMessage/portalResMessage_form-01"],
        noDataFlag: "",
        success: "提交成功",
        submitRepeat: " 1分鐘內無(wú)法重復提交",
        submitError: " 暫時(shí)無(wú)法正常提交，請您稍后再試",
        submitUrl: "",
        submitTarget: "",
        selectId: "1"
    })
</script>
</div></div>       </div>  </div></div></div>       </div>  </div></div></div>       </div>  </div></div><div   class="chvltdp5"   id="w_grid-1592803861901" class="w_grid-000"><div   id="chvltdp5"   class="w_grid signal">   <div   id="chvltdp5"   class="e_box e_box-000 p_gridbox">         <div   class="chvltdp5"   id="content_box-1592803861901-0" class="e_box e_box-000 d_gridCell_0 p_gridCell"><div   class="chvltdp5"   id="w_common_text-1592803861974" class="reset_style"><div><p style="text-align:center"><span style="color:#FFFFFF">版權所有◎2021   荊州市津楚保安服務(wù)有限公司   </span><a  target="_blank"><span style="color:#FFFFFF">鄂ICP備15013365號-1</span></a><span style="color:#FFFFFF">   網(wǎng)站制作：</span><a  target="_blank"><span style="color:#FFFFFF">新網(wǎng)</span></a></p>
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荊州市第一人民醫院