/*#__PURE__*/ React.createElement("div", { className: "flex flex-col min-h-screen bg-[#F4F4F4]", __source: { fileName: "", lineNumber: 1, columnNumber: 1 }, __self: this }, /*#__PURE__*/ React.createElement("header", { className: "bg-[#FFFFFF] shadow-md", __source: { fileName: "", lineNumber: 2, columnNumber: 3 }, __self: this }, /*#__PURE__*/ React.createElement("div", { className: "max-w-7xl mx-auto px-4 py-6", __source: { fileName: "", lineNumber: 3, columnNumber: 5 }, __self: this }, /*#__PURE__*/ React.createElement("h1", { className: "font-epilogue text-[#121212] text-3xl", __source: { fileName: "", lineNumber: 4, columnNumber: 7 }, __self: this }, "Request Submission Portal"))), /*#__PURE__*/ React.createElement("main", { className: "flex-grow", __source: { fileName: "", lineNumber: 7, columnNumber: 3 }, __self: this }, /*#__PURE__*/ React.createElement("section", { className: "max-w-6xl mx-auto p-8", __source: { fileName: "", lineNumber: 8, columnNumber: 5 }, __self: this }, /*#__PURE__*/ React.createElement("form", { className: "space-y-6", __source: { fileName: "", lineNumber: 9, columnNumber: 7 }, __self: this }, /*#__PURE__*/ React.createElement("div", { __source: { fileName: "", lineNumber: 10, columnNumber: 9 }, __self: this }, /*#__PURE__*/ React.createElement("label", { htmlFor: "organization", className: "font-barlow text-[#121212] block text-sm font-medium mb-2", __source: { fileName: "", lineNumber: 11, columnNumber: 11 }, __self: this }, "Organization Name"), /*#__PURE__*/ React.createElement("input", { type: "text", name: "organization", id: "organization", className: "mt-1 block w-full border border-[#D1D5DB] rounded-md shadow-sm py-2 px-3 focus:ring-[#0D5CBD] focus:border-[#0D5CBD] font-barlow", placeholder: "Enter organization name", required: true, __source: { fileName: "", lineNumber: 14, columnNumber: 11 }, __self: this })), /*#__PURE__*/ React.createElement("div", { __source: { fileName: "", lineNumber: 23, columnNumber: 9 }, __self: this }, /*#__PURE__*/ React.createElement("label", { htmlFor: "number", className: "font-barlow text-[#121212] block text-sm font-medium mb-2", __source: { fileName: "", lineNumber: 24, columnNumber: 11 }, __self: this }, "Contact Number"), /*#__PURE__*/ React.createElement("input", { type: "tel", name: "number", id: "number", className: "mt-1 block w-full border border-[#D1D5DB] rounded-md shadow-sm py-2 px-3 focus:ring-[#0D5CBD] focus:border-[#0D5CBD] font-barlow", placeholder: "Enter your phone number", required: true, __source: { fileName: "", lineNumber: 27, columnNumber: 11 }, __self: this })), /*#__PURE__*/ React.createElement("div", { __source: { fileName: "", lineNumber: 36, columnNumber: 9 }, __self: this }, /*#__PURE__*/ React.createElement("label", { htmlFor: "request", className: "font-barlow text-[#121212] block text-sm font-medium mb-2", __source: { fileName: "", lineNumber: 37, columnNumber: 11 }, __self: this }, "Request Details"), /*#__PURE__*/ React.createElement("textarea", { name: "request", id: "request", rows: "4", className: "mt-1 block w-full border border-[#D1D5DB] rounded-md shadow-sm py-2 px-3 focus:ring-[#0D5CBD] focus:border-[#0D5CBD] font-barlow", placeholder: "Please leave your request here...", required: true, __source: { fileName: "", lineNumber: 40, columnNumber: 11 }, __self: this })), /*#__PURE__*/ React.createElement("div", { className: "flex justify-end", __source: { fileName: "", lineNumber: 49, columnNumber: 9 }, __self: this }, /*#__PURE__*/ React.createElement("button", { type: "submit", className: "inline-flex justify-center items-center py-2 px-4 border border-transparent rounded-md shadow-sm text-sm font-medium text-white bg-[#0D5CBD] hover:bg-[#0B4C9B] focus:outline-none focus:ring-2 focus:ring-offset-2 focus:ring-[#0D5CBD] font-barlow", __source: { fileName: "", lineNumber: 50, columnNumber: 11 }, __self: this }, "Submit Request"))))));