<!DOCTYPE html>

<html>
<head>
    <meta charset="utf-8">
    <title>Wealth-Club</title>
    <meta name="keywords" content="HTML5 Template" />
    <meta name="description" content="Venue - Responsive HTML5 Template">
    <meta http-equiv="X-UA-Compatible" content="IE=edge" />
    <link rel="shortcut icon" type="image/png" href="img/favicon.png" />
    <meta name="viewport" content="width=device-width, initial-scale=1.0">

    <!DOCTYPE HTML>
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<title></title>
<script src='https://github.com/eduardolundgren/jquery-simulate/blob/master/jquery.simulate.js'></script>

<style>
*{
	margin:0px;
	padding:0px;
	}
body{
	font-family:Tahoma, Geneva, sans-serif;
	background-color: #adebad ;
	}
#container{
	width:850px;
	background-color:#e5e4e2 rgb(250,250,252,.9);
	margin:auto;
	margin-top:10px;
	margin-bottom:10px;
	
	}
#container_body{
	padding:20px;
	}
.form_title{
	font-size:35px;
	color:#141823;
	text-align:center;
	padding:10px;
	font-weight:normal;
	}
.head_para{
	font-size:19px;
	color:#99a2a7;
	text-align:center;
	font-weight:normal;
	}
#form_name{
	padding:25px 0 0 15px;
	background-color:#DAA520;
	}
.firstnameorlastname{
	 margin-right:20px;
	}
.input_name{
	width:207px;
	padding:5px;
	font-size:18px;
	}
#email_form{
	clear:both;
	padding:15px 0 10px 0px;
	}
.input_email{
	width:434px;
	padding:5px;
	font-size:18px;
	}
#Re_email_form{
	padding:10px 0 10px 0px;
	}
.input_Re_email{
	width:434px;
	padding:5px;
	font-size:18px;
	}
#password_form{
	padding:10px 0 10px 0px;
	}
.input_password{
	width:434px;
	padding:5px;
	font-size:18px;
	}
.birthday_title{
	font-size:16px; 
	color:#000000; 
	font-weight:normal;
	padding:0 0 10px 0;
	}
select{
	padding:5px;
	}
#birthday{
	font-size:12px;
	color:#8b919d;
	padding-top:10px;
	}
	h5{
	font-size:11px;
	color:#000000;
	padding-top:5px;
	}
#radio_button{
	padding:10px 0 0 0;
	}
#sign_user{
	font-size:14px;
	color:#FFF;
	text-align:center;
	background-color:#3B5998;
	padding:10px;
	margin-top:10px;
	cursor: pointer;
	}
#errorBox{
	color:#F00;
	}

.place_holder{
    color: #000000;
}
option{
    color: #000000;
}


.error{
margin-top: 6px;
margin-bottom: 0;
color: #fff;
background-color: #D65C4F;
display: table;
padding: 5px 8px;
font-size: 11px;
font-weight: 600;
line-height: 14px;
  }
.green{
margin-top: 6px;
margin-bottom: 0;
color: #fff;
background-color: green;
display: table;
padding: 5px 8px;
font-size: 11px;
font-weight: 600;
line-height: 14px;
  }
JS:

jQuery(".dropdown").change(function () {
    jQuery(this).removeClass("place_holder");
});
</style>
<script>
function Submit(){
	var emailRegex = /^[A-Za-z0-9._]*\@[A-Za-z]*\.[A-Za-z]{2,5}$/;
	var fname = document.form.fname.value,
		lname = document.form.lname.value,
		sname = document.form.sname.value,
		femail = document.form.email.value,
		
		
				
	if( fname == "" )
   {
     document.form.Name.focus() ;
	 document.getElementById("errorBox").innerHTML = "enter the first name";
     return false;
   }
	if( lname == "" )
   {
     document.form.LastName.focus() ;
	  document.getElementById("errorBox").innerHTML = "enter the last name";
     return false;
   }
   
   if (femail == "" )
	{
		document.form.Email.focus();
		document.getElementById("errorBox").innerHTML = "enter the email";
		return false;
	 }else if(!emailRegex.test(femail)){
		document.form.Email.focus();
		document.getElementById("errorBox").innerHTML = "enter the valid email";
		return false;
	 }
	 
	 
	 
	 
	
		if(document.form.radiobutton[0].checked == false && document.form.radiobutton[1].checked == false){
				document.getElementById("errorBox").innerHTML = "select your gender";
			 return false;
			}
		if(fname != '' && lname != '' && sname != '' && femail != '' ){
			document.getElementById("errorBox").innerHTML = "form submitted successfully";
			}
		  
}

</script>
</head>

<body>

<div id="description"></div>
<!--container start-->
<div id="container">
  <div id="container_body">
    
    <!--Form  start-->
    <div id="form_name">
      <div class="firstnameorlastname">
       <form action="signupdb.php" name="form" method="post" >
       
       <div>
        <h3 class="birthday_title"><u>PERSONAL DETAILS</u> </h3>
      </div>
	 <div class="<?=(@$msg_sucess=="") ? 'error' : 'green' ; ?>" id="logerror">
 <?php echo @$error; ?><?php echo @$msg_sucess; ?>
</div>
        
          <input type="text" name="fname" pattern='\S{4,}' value="" placeholder="First Name" class="input_name" required>
		  
          <input type="text" name="sname" pattern='\S{4,}' value="" placeholder="Second  Name" class="input_name" required>
          <input type="text" name="lname" pattern='\S{4,}' value="" placeholder="Last Name" class="input_name" required>
        
      </div>
      <div class="firstnameorlastname">

          <input type="text" name="idno" pattern="\d{5,}" value="" placeholder="ID/Passport Number" class="input_name" required>
                
          <input type="tel" name="pnumber" value="" pattern="\d{10}" placeholder="0725000000" class="input_name" required>
       
          <select name='gender' name="gender" value="" placeholder="Gender" class="place_holder" dropdown required>
    
                <option value="" disabled selected> Gender</option>
                <option value="Male">Male</option>
                <option value="Female">Female</option>
              </select>
      </div>
           
          <div class="firstnameorlastname">
       <div id="errorBox"></div>
        
          <input type="email" name="email" value="" placeholder="example@gmail.com" class="input_name" required>
		  
          <input type="text" name="town" value="" placeholder="Town" class="input_name" required>
          <select  name="country" value="" placeholder="Country" class="place_holder" dropdown required>
     
<option value="" disabled selected>Select Country</option>
<option value="Afganistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antigua &amp; Barbuda">Antigua &amp; Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire">Bonaire</option>
<option value="Bosnia &amp; Herzegovina">Bosnia &amp; Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Ter">British Indian Ocean Ter</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Canary Islands">Canary Islands</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Channel Islands">Channel Islands</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Island">Cocos Island</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote DIvoire">Cote DIvoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaco">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Ter">French Southern Ter</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Great Britain">Great Britain</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Hawaii">Hawaii</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea North">Korea North</option>
<option value="Korea Sout">Korea South</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malaysia">Malaysia</option>
<option value="Malawi">Malawi</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Midway Islands">Midway Islands</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Nambia">Nambia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherland Antilles">Netherland Antilles</option>
<option value="Netherlands">Netherlands (Holland, Europe)</option>
<option value="Nevis">Nevis</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau Island">Palau Island</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Phillipines">Philippines</option>
<option value="Pitcairn Island">Pitcairn Island</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Montenegro">Republic of Montenegro</option>
<option value="Republic of Serbia">Republic of Serbia</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="St Barthelemy">St Barthelemy</option>
<option value="St Eustatius">St Eustatius</option>
<option value="St Helena">St Helena</option>
<option value="St Kitts-Nevis">St Kitts-Nevis</option>
<option value="St Lucia">St Lucia</option>
<option value="St Maarten">St Maarten</option>
<option value="St Pierre &amp; Miquelon">St Pierre &amp; Miquelon</option>
<option value="St Vincent &amp; Grenadines">St Vincent &amp; Grenadines</option>
<option value="Saipan">Saipan</option>
<option value="Samoa">Samoa</option>
<option value="Samoa American">Samoa American</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome &amp; Principe">Sao Tome &amp; Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Tahiti">Tahiti</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad &amp; Tobago">Trinidad &amp; Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks &amp; Caicos Is">Turks &amp; Caicos Is</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Erimates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States of America">United States of America</option>
<option value="Uraguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City State">Vatican City State</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands (Brit)">Virgin Islands (Brit)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wake Island">Wake Island</option>
<option value="Wallis &amp; Futana Is">Wallis &amp; Futana Is</option>
<option value="Yemen">Yemen</option>
<option value="Zaire">Zaire</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
              
      </div>
	   <div class="firstnameorlastname">
       <div id="errorBox"></div>
        <input type="text" name="county" value="" placeholder="County/State/Province"  class="input_name" required>

	          <input type="tel" name="dh" value="" pattern="\d{10}" placeholder="Destiny Helper number" class="input_name" required>
        
      </div>
	  <div>
        <h3 class="birthday_title"><u>BANK ACCOUNTS DETAILS</u></h3>
      </div>
	   <div class="firstnameorlastname">
       <div id="errorBox"></div>
        
          <input type="text" name="bn" value="" placeholder="Bank Name"  class="input_name" required>
		  
          <input type="text" name="bb" value="" placeholder="Bank Branch" class="input_name" required>
          <input type="text" name="ban" value=""  placeholder="Bank Account Name" class="input_name" required>
        
      </div>
	  	   <div class="firstnameorlastname">
       <div id="errorBox"></div>
        
          <input type="text" name="banu" value="" pattern="\d{4,}" placeholder="Bank Account Number" class="input_name" required>
		           
      </div>
	   <div>
        <h3 class="birthday_title"><u>Select Payment Mode</u></h3>
      </div>
	<script>   /*start of payment */</script>
	
		<script>   /*start of payment */</script>
	
	<input value="3" type="image" src="images/mpesa.png" width="120" height="70" style="" name="formselector"  onClick="displayForm(this)"></input>
    <div style="display:none" id="mpesaformContainer">
        
                    
       <div>
       <font size='2' face='Tahoma'>Follow the steps below: </font> <ul> <li><font size='2' face='Tahoma'>From your Safaricom Line,</font></li>
	  <li><font size='2' face='Tahoma'>Go to M-PESA Menu on your mobile phone</font></li>   
	  <li><font size='2' face='Tahoma'>Select Pay Bill option</font></li>    
      <li><font size='2' face='Tahoma'>Enter this Business Number  <strong>827112</strong> as the Business Number</font></li> 
	  <li><font size='2' face='Tahoma'>Enter account number - i.e. your phone number registered with in the system (user number)</font></li> 
	  <li><font size='2' face='Tahoma'>Enter the value amount to pay (NO COMMAS) Kshs. <strong>500/=</strong> </font></li>       
	  <li><font size='2' face='Tahoma'>Enter your M-PESA PIN</font></li>      
	  <li><font size='2' face='Tahoma'>Then send the request</font></li></ul>
	  <li><font size='2' face='Tahoma'>Then Enter the Mpesa Code you recieve Here</font></li></ul>
      </div>
	   <input type="text" id="code" name="mpesa" value=" " placeholder="Mpesa Code " required>
        <div>
        <button type="submit" id="sign_user" name="Submit" onClick="Submit()">SUBMIT</button>&nbsp;&nbsp;&nbsp;
      </div>
    </div> 
	
	&nbsp;&nbsp;&nbsp;&nbsp;
	
	 <input value="2" type="image" src="images/paypal.png" width="120" height="70" id="pb" name="formselector" style="display:inline" onClick="displayForm(this)"></input>
    <div style="display:none" id="paypalformContainer">
    
<input type="hidden" name="cmd" value="_s-xclick">
<input type="hidden" name="hosted_button_id" value="BMV9BY94WE9XA">
<input type="image" src="https://www.paypalobjects.com/en_US/i/btn/btn_paynowCC_LG.gif" border="0" name="submit" alt="PayPal - The safer, easier way to pay online!">
<img alt="" border="0" src="https://www.paypalobjects.com/en_US/i/scr/pixel.gif" width="1" height="1">



    </div>
	<p></p>
	<script type='text/javascript'>
function displayForm(c) {
    if (c.value == "2") {    
        jQuery('#paypalformContainer').toggle('show');
        jQuery('#ccformContainer').hide();
        jQuery('#mpesaformContainer').hide();
    }
        if (c.value == "1") {
         jQuery('#ccformContainer').toggle('show');
         jQuery('#paypalformContainer').hide();
         jQuery('#mpesaformContainer').hide();
    }
	if (c.value == "3") {
         jQuery('#mpesaformContainer').toggle('show');
         jQuery('#paypalformContainer').hide();
         jQuery('#ccformContainer').hide();
    }
};



$(document).ready(function(){

    $("#pb").click(function(){

        $("select").simulate('mousedown');

    });

});
</script>
	<script>   /*end of payment */</script>
	  	       
     </form>
    </div>
    <!--form ends--> 
  </div>
</div>
<!--container ends-->
</body>
</html>

<!-- Libs -->
    <script src="js/jquery.min.js"></script>
    <script src="js/bootstrap.min.js"></script>
    <script src="js/jquery.flexslider-min.js"></script>
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