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- <img class="reg-text-center" src="/images/325/desktop_reg_Jan.png" />
- </div>
- <h2 class="reg-form-header-title reg-text-center">Tell Us About Yourself And Claim 5 Chances To Win Big!</h2>
- </div>
- <div class="reg-form-middle clearfix">
- <div class="reg-form-middle-left">
- <div class="reg-info reg-user-info gradient">
- <div class="reg-info-header reg-user-info-header"></div>
- <div class="reg-info-content reg-user-info-content gradient">
- <!-- Title -->
- <div class="reg-item reg-item-title">
- <label for="title">Title:</label>
- <select name="title" class="reg-input required title" tabindex="1"
- >
- <option selected="selected" value=""> Select </option>
- <option value="Mr.">Mr.</option>
- <option value="Mrs.">Mrs.</option>
- <option value="Ms.">Ms.</option>
- </select>
- </div>
- <!-- First name -->
- <div class="reg-item clearfix">
- <label for="firstname">First Name:</label>
- <input
- name="firstname"
- type="text"
- class="reg-input required first-name"
- maxlength="50"
- size="24"
- tabindex="2"
- value=""
- >
- </div>
- <!-- Last name -->
- <div class="reg-item clearfix">
- <label for="lastname">Last Name:</label>
- <input
- name="lastname"
- type="text"
- class="reg-input required last-name"
- maxlength="50"
- size="24"
- tabindex="3"
- value=""
- >
- </div>
- <!-- Address 1 -->
- <div class="reg-item clearfix">
- <label for="street">Street Address / P.O. Box:</label>
- <input
- name="street"
- type="text"
- class="reg-input required street"
- maxlength="64"
- size="40"
- tabindex="4"
- value=""
- >
- </div>
- <!-- Address 2 -->
- <div class="reg-item clearfix">
- <label for="apt">Apt / Suite:</label>
- <input
- name="apt"
- type="text"
- class="reg-input apt"
- maxlength="64"
- size="20"
- tabindex="5"
- value=""
- >
- </div>
- <!-- City -->
- <div class="reg-item">
- <label for="city">City:</label>
- <input
- name="city"
- type="text"
- class="reg-input required city"
- maxlength="64"
- size="20"
- tabindex="6"
- value=""
- >
- </div>
- <!-- State -->
- <div class="reg-item clearfix">
- <label for="state">State:</label>
- <select name="state" class="reg-input required state" tabindex="7">
- <!-- PHPTODO values -->
- <option selected="selected">State</option>
- <optgroup label="States">
- <option
- value="AL"
- >Alabama</option>
- <option
- value="AK"
- >Alaska</option>
- <option
- value="AZ"
- >Arizona</option>
- <option
- value="AR"
- >Arkansas</option>
- <option
- value="CA"
- >California</option>
- <option
- value="CO"
- >Colorado</option>
- <option
- value="CT"
- >Connecticut</option>
- <option
- value="DE"
- >Delaware</option>
- <option
- value="DC"
- >District Of Columbia</option>
- <option
- value="FL"
- >Florida</option>
- <option
- value="GA"
- >Georgia</option>
- <option
- value="HI"
- >Hawaii</option>
- <option
- value="ID"
- >Idaho</option>
- <option
- value="IL"
- >Illinois</option>
- <option
- value="IN"
- >Indiana</option>
- <option
- value="IA"
- >Iowa</option>
- <option
- value="KS"
- >Kansas</option>
- <option
- value="KY"
- >Kentucky</option>
- <option
- value="LA"
- >Louisiana</option>
- <option
- value="ME"
- >Maine</option>
- <option
- value="MD"
- >Maryland</option>
- <option
- value="MA"
- >Massachusetts</option>
- <option
- value="MI"
- >Michigan</option>
- <option
- value="MN"
- >Minnesota</option>
- <option
- value="MS"
- >Mississippi</option>
- <option
- value="MO"
- >Missouri</option>
- <option
- value="MT"
- >Montana</option>
- <option
- value="NE"
- >Nebraska</option>
- <option
- value="NV"
- >Nevada</option>
- <option
- value="NH"
- >New Hampshire</option>
- <option
- value="NJ"
- >New Jersey</option>
- <option
- value="NM"
- >New Mexico</option>
- <option
- value="NY"
- >New York</option>
- <option
- value="NC"
- >North Carolina</option>
- <option
- value="ND"
- >North Dakota</option>
- <option
- value="OH"
- >Ohio</option>
- <option
- value="OK"
- >Oklahoma</option>
- <option
- value="OR"
- >Oregon</option>
- <option
- value="PA"
- >Pennsylvania</option>
- <option
- value="PR"
- >Puerto Rico</option>
- <option
- value="RI"
- >Rhode Island</option>
- <option
- value="SC"
- >South Carolina</option>
- <option
- value="SD"
- >South Dakota</option>
- <option
- value="TN"
- >Tennessee</option>
- <option
- value="TX"
- >Texas</option>
- <option
- value="UT"
- >Utah</option>
- <option
- value="VT"
- >Vermont</option>
- <option
- value="VA"
- >Virginia</option>
- <option
- value="WA"
- >Washington</option>
- <option
- value="WV"
- >West Virginia</option>
- <option
- value="WI"
- >Wisconsin</option>
- <option
- value="WY"
- >Wyoming</option>
- </optgroup>
- <optgroup label="APO/FPO">
- <option
- value="AA"
- >APO/FPO AA</option>
- <option
- value="AE"
- >APO/FPO AE</option>
- <option
- value="AP"
- >APO/FPO AP</option>
- </optgroup>
- </select>
- </div>
- <!-- Zip -->
- <div class="reg-item clearfix">
- <label for="zip">Zip:</label>
- <input
- name="zip"
- type="text"
- class="reg-input required zip"
- maxlength="5"
- size="11"
- tabindex="8"
- max="99999"
- value=""
- >
- </div>
- </div>
- </div>
- <div class="reg-info reg-user-site-info gradient">
- <div class="reg-info-header reg-user-site-info-header"></div>
- <div class="reg-info-content reg-user-site-info-content gradient">
- <!-- Screen Name -->
- <!-- DOB -->
- <div class="dob reg-item clearfix">
- <label>Date of Birth:</label>
- <input name="dob" type="hidden" value="">
- <select class="reg-input month" tabindex="9">
- <option value="00">Month</option>
- <option value="01" >January</option><option value="02" >February</option><option value="03" >March</option><option value="04" >April</option><option value="05" >May</option><option value="06" >June</option><option value="07" >July</option><option value="08" >August</option><option value="09" >September</option><option value="10" >October</option><option value="11" >November</option><option value="12" >December</option> </select>
- <select class="reg-input day" tabindex="10">
- <option value="00">Day</option>
- <option value="01" >01</option><option value="02" >02</option><option value="03" >03</option><option value="04" >04</option><option value="05" >05</option><option value="06" >06</option><option value="07" >07</option><option value="08" >08</option><option value="09" >09</option><option value="10" >10</option><option value="11" >11</option><option value="12" >12</option><option value="13" >13</option><option value="14" >14</option><option value="15" >15</option><option value="16" >16</option><option value="17" >17</option><option value="18" >18</option><option value="19" >19</option><option value="20" >20</option><option value="21" >21</option><option value="22" >22</option><option value="23" >23</option><option value="24" >24</option><option value="25" >25</option><option value="26" >26</option><option value="27" >27</option><option value="28" >28</option><option value="29" >29</option><option value="30" >30</option><option value="31" >31</option> </select>
- <select class="reg-input year" tabindex="11">
- <option value="0000">Year</option>
- <option value="2021" >2021</option><option value="2020" >2020</option><option value="2019" >2019</option><option value="2018" >2018</option><option value="2017" >2017</option><option value="2016" >2016</option><option value="2015" >2015</option><option value="2014" >2014</option><option value="2013" >2013</option><option value="2012" >2012</option><option value="2011" >2011</option><option value="2010" >2010</option><option value="2009" >2009</option><option value="2008" >2008</option><option value="2007" >2007</option><option value="2006" >2006</option><option value="2005" >2005</option><option value="2004" >2004</option><option value="2003" >2003</option><option value="2002" >2002</option><option value="2001" >2001</option><option value="2000" >2000</option><option value="1999" >1999</option><option value="1998" >1998</option><option value="1997" >1997</option><option value="1996" >1996</option><option value="1995" >1995</option><option value="1994" >1994</option><option value="1993" >1993</option><option value="1992" >1992</option><option value="1991" >1991</option><option value="1990" >1990</option><option value="1989" >1989</option><option value="1988" >1988</option><option value="1987" >1987</option><option value="1986" >1986</option><option value="1985" >1985</option><option value="1984" >1984</option><option value="1983" >1983</option><option value="1982" >1982</option><option value="1981" >1981</option><option value="1980" >1980</option><option value="1979" >1979</option><option value="1978" >1978</option><option value="1977" >1977</option><option value="1976" >1976</option><option value="1975" >1975</option><option value="1974" >1974</option><option value="1973" >1973</option><option value="1972" >1972</option><option value="1971" >1971</option><option value="1970" >1970</option><option value="1969" >1969</option><option value="1968" >1968</option><option value="1967" >1967</option><option value="1966" >1966</option><option value="1965" >1965</option><option value="1964" >1964</option><option value="1963" >1963</option><option value="1962" >1962</option><option value="1961" >1961</option><option value="1960" >1960</option><option value="1959" >1959</option><option value="1958" >1958</option><option value="1957" >1957</option><option value="1956" >1956</option><option value="1955" >1955</option><option value="1954" >1954</option><option value="1953" >1953</option><option value="1952" >1952</option><option value="1951" >1951</option><option value="1950" >1950</option><option value="1949" >1949</option><option value="1948" >1948</option><option value="1947" >1947</option><option value="1946" >1946</option><option value="1945" >1945</option><option value="1944" >1944</option><option value="1943" >1943</option><option value="1942" >1942</option><option value="1941" >1941</option><option value="1940" >1940</option><option value="1939" >1939</option><option value="1938" >1938</option><option value="1937" >1937</option><option value="1936" >1936</option><option value="1935" >1935</option><option value="1934" >1934</option><option value="1933" >1933</option><option value="1932" >1932</option><option value="1931" >1931</option><option value="1930" >1930</option><option value="1929" >1929</option><option value="1928" >1928</option><option value="1927" >1927</option><option value="1926" >1926</option><option value="1925" >1925</option><option value="1924" >1924</option><option value="1923" >1923</option><option value="1922" >1922</option><option value="1921" >1921</option><option value="1920" >1920</option><option value="1919" >1919</option><option value="1918" >1918</option><option value="1917" >1917</option><option value="1916" >1916</option><option value="1915" >1915</option><option value="1914" >1914</option><option value="1913" >1913</option><option value="1912" >1912</option><option value="1911" >1911</option><option value="1910" >1910</option><option value="1909" >1909</option><option value="1908" >1908</option><option value="1907" >1907</option><option value="1906" >1906</option><option value="1905" >1905</option><option value="1904" >1904</option><option value="1903" >1903</option><option value="1902" >1902</option> </select>
- </div>
- <!-- Email -->
- <div class="email-container clearfix">
- <div class="reg-item clearfix">
- <label for="email">Email:</label>
- <input
- name="email"
- type="text"
- class="reg-input required email"
- maxlength="50"
- size="30"
- tabindex="12"
- value=""
- >
- </div>
- <div class="reg-item clearfix">
- <label for="confirm-email">Confirm Email:</label>
- <input
- name="confirm-email"
- type="text"
- class="reg-input required confirm-email"
- maxlength="50"
- size="30"
- tabindex="13"
- value=""
- >
- </div>
- </div>
- <!-- Password -->
- <div class="password-container clearfix">
- <div class="reg-item clearfix">
- <label for="password">Password:</label>
- <input
- name="password"
- type="password"
- class="reg-input required password"
- maxlength="50"
- size="30"
- tabindex="14"
- value=""
- >
- </div>
- <!-- For lotto -->
- <div class="just-one-password-container">
- <div class="just-one-password">
- <div class="hand"></div>
- <p class="just-one-password-text">
- <span>JUST ONE PASSWORD!</span>
- <br>
- <b>is all it takes to access any of our PCH sites.</b>
- </p>
- </div>
- </div>
- <div class="reg-item clearfix">
- <label for="confirm-password">Confirm Password:</label>
- <input
- name="confirm-password"
- type="password"
- class="reg-input required confirm-password"
- maxlength="50"
- size="30"
- tabindex="15"
- value=""
- >
- </div>
- </div>
- </div>
- </div>
- </div>
- <!-- Optional, can be used for lotto right column banner or simply hidden -->
- <div class="reg-form-middle-right">
- <div class="reg-ad" style="background: url()"></div>
- </div>
- </div>
- <div class="reg-form-bottom clearfix">
- <div class="signed-in">
- <input type="checkbox" tabindex="16" class="keep-me-signed-in" checked>
- <span class="remember-me">Keep me signed in.</span>
- </div>
- <!-- Optins -->
- <div class="optin-div gradient">
- <input class="optin" id="optin1" tabindex="17" type="checkbox" checked>
- <div class="optin-copy">Yes, I'd like to be informed about chances to win prizes instantly from PCH Search&Win. I know I can unsubscribe at any time by clicking the unsub link or the "EZ Unsubscribe" seal in any email. <a href="http://privacy.pch.com" rel="nofollow" target="_blank">Privacy Policy</a></div>
- <div class="optin-ez-unsub"></div>
- </div>
- <div class="optin-div gradient">
- <input class="optin" id="optin2" tabindex="18" type="checkbox" checked>
- <div class="optin-copy">Yes! I'd like to be informed about chances to win and offers from pch.com. I know I can unsubscribe at any time. <a href="https://privacy.pch.com" rel="nofollow" target="_blank">Privacy Policy</a></div>
- <div class="optin-ez-unsub"></div>
- </div>
- <div class="submit-container clearfix">
- <div class="submit-container-inner gradient">
- <!-- PHPTODO option for button image, otherwise CSS button -->
- <button
- id="sub_btn"
- type="button"
- class="submit-button"
- style="background: url('/images/325/submit-btn_win.png') no-repeat;"
- >
- <span class="but-text"></span>
- </button>
- <div class="btn-arrow">
- <span class="btn-arrow-right"></span>
- </div>
- </div>
- </div>
- <p class="privacy">
- By entering this site, I understand and agree to the <a tabindex="19" type="image" value="Submit Claim Form" rel="nofollow" target="_blank" href="https://privacy.pch.com">
- Privacy Policy</a>of PCH Search&Win.
- </p>
- <p class="footer-copy"></p>
- </div>
- </form>
- </div>
- <script>
- $(document).ready(function() {
- if (window.header_links) {
- $('.link-group').html(header_links);
- }
- PCH.Registration.initialize({
- container: $('#pch-reg-form .reg-form-middle-left'),
- subBtn: $('.submit-container-inner')
- });
- });
- </script>
- <script>
- function openit2 (sURL, w, h) {
- newwindow = window.open(sURL,"nextwin","scrollbars=yes,toolbar=no,directories=no,menubar=no,resizable=yes,status=no,width="+w+",height="+h+"");
- newwindow.window.focus();
- }
- </script>
- </div>
- <footer>
- <div class="logos">
- <div class="custom" >
- <img src="/templates/accounts/images/pchcom.png">
- <div class="divider"></div>
- <img src="/templates/accounts/images/search.png">
- <div class="divider"></div>
- <img src="/templates/accounts/images/frontpage.png">
- <div class="divider"></div>
- <img src="/templates/accounts/images/lotto.png">
- <div class="divider"></div>
- <img src="/templates/accounts/images/slots.png">
- <div class="divider"></div>
- <img src="/templates/accounts/images/games.png">
- </div>
- </div>
- <p class="copyright">Copyright © 2021 Publishers Clearing House. All rights reserved.</p>
- </footer>
- <!-- Scripts -->
- <script src="https://scdn.pch.com/RegistrationFoundation/V9/SSO/build/prod/sso_lib_desktop_min.js?v=0.0.2597-1999"></script>
- <div class="custom" >
- <style>
- .copyright {
- display: none;
- }
- .copyright2 {
- font-size: 11px;
- text-align: center;
- margin: 0 auto;
- max-width: 500px;
- color: #666;
- }
- </style>
- <div class="copyright2">
- <p>Copyright © 2004-<span id="copyright_year"></span> Publishers Clearing House. All rights reserved.</p>
- <p>All trademarks and registered trademarks appearing on this site are the property of their respective owners. Said owners do not endorse nor are they affiliated with Publishers Clearing House or its promotions.</p>
- </div>
- <script>
- var year = (new Date()).getFullYear();
- document.getElementById('copyright_year').innerHTML = year;
- </script></div>
- <script src="/dist/js/account.min.js?v=0.0.2597-1999" type="text/javascript"></script>
- <script src="/dist/js/jquery.infieldlabel.min.js?v=0.0.2597-1999" type="text/javascript"></script>
- <script src="/dist/js/pchTagManager.min.js?v=0.0.2597-1999" type="text/javascript"></script>
- <script src="/dist/js/json2.min.js?v=0.0.2597-1999" type="text/javascript"></script>
- <script type='text/javascript'>
- window.header_links = "<a href=\"https:\/\/search.pch.com\/about\">About PCHSearch&Win<\/a> | \r\n<a href=\"https:\/\/search.pch.com\/howto\">How To Search<\/a> | \r\n<a href=\"https:\/\/search.pch.com\/help\">Help<\/a> | \r\n<a href=\"javascript:openit2('https:\/\/rules.pch.com\/viewrulesfacts?type=searchreg','600px','400px')\">Official Rules\/Entry Deadline<\/a> | \r\n<a href=\"javascript:openit2('https:\/\/rules.pch.com\/viewrulesfacts?type=searchreg#facts','550px','400px')\">See Sweepstakes Facts<\/a>";
- window.optin_app_1 = "SEARCH";
- window.optin_app_2 = "PCHCOM";
- </script>
- <script type="text/javascript">window.NREUM||(NREUM={});NREUM.info={"beacon":"bam-cell.nr-data.net","licenseKey":"c72205da0c","applicationID":"9847367","transactionName":"NgMGZhFWC0VWUk1bDg9JJVEXXgpYGGFaWjMEAQ1BF0UEQl5eV3EODxIWXQ9bAEQYVVBBEQ0HHQ==","queueTime":0,"applicationTime":33,"atts":"GkQFEFlMGEs=","errorBeacon":"bam-cell.nr-data.net","agent":""}</script></body>
- </html>
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