<?php  include "../includes/header.php"; ?>

<style>
    .container {
        padding: 15px;
        background: var(--dark-blue);
        border-radius: 5px;
        color: var(--text-color);
    }
    article .fa {
        font-size: 12px;
        color: dodgerblue;
    }

    .container button {
        padding: 10px 50px;
        border: 1px solid transparent;
        background: dodgerblue;
        color: var(--text-color);
        margin: 10px 0;
        border-radius: 3px;
        font-weight: bold;
    }
    hr {
            border: 1px solid transparent;
            border-bottom: 1px solid var(--text );
        }

        form input, form select {
        padding: 10px; 
        border-radius: 3px;
        border: 1px solid var(--hover);
        display: block;
        width: 100%;
        background: var(--primary);
        color: var(--text-color);
        margin: 10px 0;
        font-size: 12px;
    }
    form label {
        margin: 20px 0;
        font-size: 14px;
        color: var(--text-color);
    }
    form button {
        background: dodgerblue;
        padding: 9px 15px;
        display: flex;
        align-items: center;
        color: white;
        border: 1px solid dodgerblue;
        border-radius: 3px;
        margin: 5px 0;
    }
    form sup {
        color: red;
    }
    @media screen and (min-width: 768px) {
        .input-grid {
            display: grid; 
            grid-template-columns: 1fr 1fr;
        }
        .input-grid article {
            margin: 5px;
        }
        .input-grid:nth-child(2), .input-grid:nth-child(3) {
            display: grid; 
            grid-template-columns: 1fr 1fr 1fr;
        }
    }

    @media screen and (min-width: 1200px) {}
</style>

<style>
        @media screen and (min-width: 768px) {
            .fixed-width {
                width: 100%;
                margin: 0 0%;
            }
            
            .side-panel-right {
                display: none;
                width: 30%;
            }
        }

        @media screen and (min-width: 1200px) {
            .fixed-width {
                width: 80%;
                transform: translateX(5%);
                margin: 0 15%;
            }

            .side-panel-left {
                width: 20%;
                display: block;
            }
        }
    </style>

 <div class="container">
       <div class="container-text">
      <center> <img src="../images/<?php echo $image?>" width="100px" height='100px' style='border-radius: 5px'></center>
           <p style='font-size: 34px; text-align: center;'>Begin your ID-Verification</p><br>
           <p style='font-size: 14px; line-height: 30px; padding: 3px 10%; text-align: center; color: var(--text)'>To comply with regulation each participant will have to go through identity verification (KYC/AML) to prevent fraud causes.</p><br><br>
       </div>

       <div class="form" style='background: var(--primary-two); padding: 20px'>
            <div style='display: flex; align-items: center; color: var(--text)'>
                <span style='margin-right: 20px; border: 2px solid var(--text); padding: 5px; border-radius: 50%'>01</span>
                <span><h3>Personal Details</h3>
                     <p style='font-size: 13px'>Your simple personal information required for identification</p>
                </span>
            </div><br><hr><br>
            <p style='font-size: 13px; color: var(--text); padding: 10px'><i class="fa fa-question-circle-o" style='font-size: 10px'></i> Please type carefully and fill out the form with your personal details. Your can’t edit these details once you submitted the form.</p><br>

            <?php
                 include "../database/kyc_script.php";
                 $kyc_session = '';
                $sql = "SELECT * FROM kyc WHERE kyc_user_id = '$user_id'";
                $result = $connection->query($sql);
                while ($row = $result->fetch_assoc()) {
                    $kyc_session = $row['kyc_session'];
                }  
                  
                if ($kyc_session == 1) {
                    echo "<script>window.location.href = 'kyc-form-address'</script>";
                }else if ($kyc_session == 2) {
                    echo "<script>window.location.href = 'kyc_form_upload'</script>";
                } 
            ?>
        <form action="" method="post">
            <div class="input-grid">
                <article>
                    <label for="">First Name<sup>*</sup></label>
                    <input type="text" name='fname' required>
                </article>

                <article>
                    <label for="">Last Name <sup>*</sup></label>
                    <input type="text" name='lname' required>
                </article>

                <article>
                    <label for="">Email<sup>*</sup></label>
                    <input type="email" name='email' required>
                </article>

                <article>
                    <label for="">Gender <sup>*</sup></label>
                    <select name='gender' required style='text-align: left'>
                        <option value="">select option</option>
                        <option value="Male">Male</option>
                        <option value="Female">Female</option>
                    </select>
                </article>
            </div>

            <div class="input-grid">
            <article>
                <label for=""> Country Code <sup>*</sup></label>
                <select name="country_code" required>
                    <option value="">Select country code</option>
                    <option data-countryCode="GB" value="44" >UK (+44)</option>
                    <option data-countryCode="US" value="1">USA (+1)</option>
                    <optgroup label="Other countries">
                    <option data-countryCode="DZ" value="213">Algeria (+213)</option>
                    <option data-countryCode="AD" value="376">Andorra (+376)</option>
                    <option data-countryCode="AO" value="244">Angola (+244)</option>
                    <option data-countryCode="AI" value="1264">Anguilla (+1264)</option>
                    <option data-countryCode="AG" value="1268">Antigua &amp; Barbuda (+1268)</option>
                    <option data-countryCode="AR" value="54">Argentina (+54)</option>
                    <option data-countryCode="AM" value="374">Armenia (+374)</option>
                    <option data-countryCode="AW" value="297">Aruba (+297)</option>
                    <option data-countryCode="AU" value="61">Australia (+61)</option>
                    <option data-countryCode="AT" value="43">Austria (+43)</option>
                    <option data-countryCode="AZ" value="994">Azerbaijan (+994)</option>
                    <option data-countryCode="BS" value="1242">Bahamas (+1242)</option>
                    <option data-countryCode="BH" value="973">Bahrain (+973)</option>
                    <option data-countryCode="BD" value="880">Bangladesh (+880)</option>
                    <option data-countryCode="BB" value="1246">Barbados (+1246)</option>
                    <option data-countryCode="BY" value="375">Belarus (+375)</option>
                    <option data-countryCode="BE" value="32">Belgium (+32)</option>
                    <option data-countryCode="BZ" value="501">Belize (+501)</option>
                    <option data-countryCode="BJ" value="229">Benin (+229)</option>
                    <option data-countryCode="BM" value="1441">Bermuda (+1441)</option>
                    <option data-countryCode="BT" value="975">Bhutan (+975)</option>
                    <option data-countryCode="BO" value="591">Bolivia (+591)</option>
                    <option data-countryCode="BA" value="387">Bosnia Herzegovina (+387)</option>
                    <option data-countryCode="BW" value="267">Botswana (+267)</option>
                    <option data-countryCode="BR" value="55">Brazil (+55)</option>
                    <option data-countryCode="BN" value="673">Brunei (+673)</option>
                    <option data-countryCode="BG" value="359">Bulgaria (+359)</option>
                    <option data-countryCode="BF" value="226">Burkina Faso (+226)</option>
                    <option data-countryCode="BI" value="257">Burundi (+257)</option>
                    <option data-countryCode="KH" value="855">Cambodia (+855)</option>
                    <option data-countryCode="CM" value="237">Cameroon (+237)</option>
                    <option data-countryCode="CA" value="1">Canada (+1)</option>
                    <option data-countryCode="CV" value="238">Cape Verde Islands (+238)</option>
                    <option data-countryCode="KY" value="1345">Cayman Islands (+1345)</option>
                    <option data-countryCode="CF" value="236">Central African Republic (+236)</option>
                    <option data-countryCode="CL" value="56">Chile (+56)</option>
                    <option data-countryCode="CN" value="86">China (+86)</option>
                    <option data-countryCode="CO" value="57">Colombia (+57)</option>
                    <option data-countryCode="KM" value="269">Comoros (+269)</option>
                    <option data-countryCode="CG" value="242">Congo (+242)</option>
                    <option data-countryCode="CK" value="682">Cook Islands (+682)</option>
                    <option data-countryCode="CR" value="506">Costa Rica (+506)</option>
                    <option data-countryCode="HR" value="385">Croatia (+385)</option>
                    <option data-countryCode="CU" value="53">Cuba (+53)</option>
                    <option data-countryCode="CY" value="90392">Cyprus North (+90392)</option>
                    <option data-countryCode="CY" value="357">Cyprus South (+357)</option>
                    <option data-countryCode="CZ" value="42">Czech Republic (+42)</option>
                    <option data-countryCode="DK" value="45">Denmark (+45)</option>
                    <option data-countryCode="DJ" value="253">Djibouti (+253)</option>
                    <option data-countryCode="DM" value="1809">Dominica (+1809)</option>
                    <option data-countryCode="DO" value="1809">Dominican Republic (+1809)</option>
                    <option data-countryCode="EC" value="593">Ecuador (+593)</option>
                    <option data-countryCode="EG" value="20">Egypt (+20)</option>
                    <option data-countryCode="SV" value="503">El Salvador (+503)</option>
                    <option data-countryCode="GQ" value="240">Equatorial Guinea (+240)</option>
                    <option data-countryCode="ER" value="291">Eritrea (+291)</option>
                    <option data-countryCode="EE" value="372">Estonia (+372)</option>
                    <option data-countryCode="ET" value="251">Ethiopia (+251)</option>
                    <option data-countryCode="FK" value="500">Falkland Islands (+500)</option>
                    <option data-countryCode="FO" value="298">Faroe Islands (+298)</option>
                    <option data-countryCode="FJ" value="679">Fiji (+679)</option>
                    <option data-countryCode="FI" value="358">Finland (+358)</option>
                    <option data-countryCode="FR" value="33">France (+33)</option>
                    <option data-countryCode="GF" value="594">French Guiana (+594)</option>
                    <option data-countryCode="PF" value="689">French Polynesia (+689)</option>
                    <option data-countryCode="GA" value="241">Gabon (+241)</option>
                    <option data-countryCode="GM" value="220">Gambia (+220)</option>
                    <option data-countryCode="GE" value="7880">Georgia (+7880)</option>
                    <option data-countryCode="DE" value="49">Germany (+49)</option>
                    <option data-countryCode="GH" value="233">Ghana (+233)</option>
                    <option data-countryCode="GI" value="350">Gibraltar (+350)</option>
                    <option data-countryCode="GR" value="30">Greece (+30)</option>
                    <option data-countryCode="GL" value="299">Greenland (+299)</option>
                    <option data-countryCode="GD" value="1473">Grenada (+1473)</option>
                    <option data-countryCode="GP" value="590">Guadeloupe (+590)</option>
                    <option data-countryCode="GU" value="671">Guam (+671)</option>
                    <option data-countryCode="GT" value="502">Guatemala (+502)</option>
                    <option data-countryCode="GN" value="224">Guinea (+224)</option>
                    <option data-countryCode="GW" value="245">Guinea - Bissau (+245)</option>
                    <option data-countryCode="GY" value="592">Guyana (+592)</option>
                    <option data-countryCode="HT" value="509">Haiti (+509)</option>
                    <option data-countryCode="HN" value="504">Honduras (+504)</option>
                    <option data-countryCode="HK" value="852">Hong Kong (+852)</option>
                    <option data-countryCode="HU" value="36">Hungary (+36)</option>
                    <option data-countryCode="IS" value="354">Iceland (+354)</option>
                    <option data-countryCode="IN" value="91">India (+91)</option>
                    <option data-countryCode="ID" value="62">Indonesia (+62)</option>
                    <option data-countryCode="IR" value="98">Iran (+98)</option>
                    <option data-countryCode="IQ" value="964">Iraq (+964)</option>
                    <option data-countryCode="IE" value="353">Ireland (+353)</option>
                    <option data-countryCode="IL" value="972">Israel (+972)</option>
                    <option data-countryCode="IT" value="39">Italy (+39)</option>
                    <option data-countryCode="JM" value="1876">Jamaica (+1876)</option>
                    <option data-countryCode="JP" value="81">Japan (+81)</option>
                    <option data-countryCode="JO" value="962">Jordan (+962)</option>
                    <option data-countryCode="KZ" value="7">Kazakhstan (+7)</option>
                    <option data-countryCode="KE" value="254">Kenya (+254)</option>
                    <option data-countryCode="KI" value="686">Kiribati (+686)</option>
                    <option data-countryCode="KP" value="850">Korea North (+850)</option>
                    <option data-countryCode="KR" value="82">Korea South (+82)</option>
                    <option data-countryCode="KW" value="965">Kuwait (+965)</option>
                    <option data-countryCode="KG" value="996">Kyrgyzstan (+996)</option>
                    <option data-countryCode="LA" value="856">Laos (+856)</option>
                    <option data-countryCode="LV" value="371">Latvia (+371)</option>
                    <option data-countryCode="LB" value="961">Lebanon (+961)</option>
                    <option data-countryCode="LS" value="266">Lesotho (+266)</option>
                    <option data-countryCode="LR" value="231">Liberia (+231)</option>
                    <option data-countryCode="LY" value="218">Libya (+218)</option>
                    <option data-countryCode="LI" value="417">Liechtenstein (+417)</option>
                    <option data-countryCode="LT" value="370">Lithuania (+370)</option>
                    <option data-countryCode="LU" value="352">Luxembourg (+352)</option>
                    <option data-countryCode="MO" value="853">Macao (+853)</option>
                    <option data-countryCode="MK" value="389">Macedonia (+389)</option>
                    <option data-countryCode="MG" value="261">Madagascar (+261)</option>
                    <option data-countryCode="MW" value="265">Malawi (+265)</option>
                    <option data-countryCode="MY" value="60">Malaysia (+60)</option>
                    <option data-countryCode="MV" value="960">Maldives (+960)</option>
                    <option data-countryCode="ML" value="223">Mali (+223)</option>
                    <option data-countryCode="MT" value="356">Malta (+356)</option>
                    <option data-countryCode="MH" value="692">Marshall Islands (+692)</option>
                    <option data-countryCode="MQ" value="596">Martinique (+596)</option>
                    <option data-countryCode="MR" value="222">Mauritania (+222)</option>
                    <option data-countryCode="YT" value="269">Mayotte (+269)</option>
                    <option data-countryCode="MX" value="52">Mexico (+52)</option>
                    <option data-countryCode="FM" value="691">Micronesia (+691)</option>
                    <option data-countryCode="MD" value="373">Moldova (+373)</option>
                    <option data-countryCode="MC" value="377">Monaco (+377)</option>
                    <option data-countryCode="MN" value="976">Mongolia (+976)</option>
                    <option data-countryCode="MS" value="1664">Montserrat (+1664)</option>
                    <option data-countryCode="MA" value="212">Morocco (+212)</option>
                    <option data-countryCode="MZ" value="258">Mozambique (+258)</option>
                    <option data-countryCode="MN" value="95">Myanmar (+95)</option>
                    <option data-countryCode="NA" value="264">Namibia (+264)</option>
                    <option data-countryCode="NR" value="674">Nauru (+674)</option>
                    <option data-countryCode="NP" value="977">Nepal (+977)</option>
                    <option data-countryCode="NL" value="31">Netherlands (+31)</option>
                    <option data-countryCode="NC" value="687">New Caledonia (+687)</option>
                    <option data-countryCode="NZ" value="64">New Zealand (+64)</option>
                    <option data-countryCode="NI" value="505">Nicaragua (+505)</option>
                    <option data-countryCode="NE" value="227">Niger (+227)</option>
                    <option data-countryCode="NG" value="234">Nigeria (+234)</option>
                    <option data-countryCode="NU" value="683">Niue (+683)</option>
                    <option data-countryCode="NF" value="672">Norfolk Islands (+672)</option>
                    <option data-countryCode="NP" value="670">Northern Marianas (+670)</option>
                    <option data-countryCode="NO" value="47">Norway (+47)</option>
                    <option data-countryCode="OM" value="968">Oman (+968)</option>
                    <option data-countryCode="PW" value="680">Palau (+680)</option>
                    <option data-countryCode="PA" value="507">Panama (+507)</option>
                    <option data-countryCode="PG" value="675">Papua New Guinea (+675)</option>
                    <option data-countryCode="PY" value="595">Paraguay (+595)</option>
                    <option data-countryCode="PE" value="51">Peru (+51)</option>
                    <option data-countryCode="PH" value="63">Philippines (+63)</option>
                    <option data-countryCode="PL" value="48">Poland (+48)</option>
                    <option data-countryCode="PT" value="351">Portugal (+351)</option>
                    <option data-countryCode="PR" value="1787">Puerto Rico (+1787)</option>
                    <option data-countryCode="QA" value="974">Qatar (+974)</option>
                    <option data-countryCode="RE" value="262">Reunion (+262)</option>
                    <option data-countryCode="RO" value="40">Romania (+40)</option>
                    <option data-countryCode="RU" value="7">Russia (+7)</option>
                    <option data-countryCode="RW" value="250">Rwanda (+250)</option>
                    <option data-countryCode="SM" value="378">San Marino (+378)</option>
                    <option data-countryCode="ST" value="239">Sao Tome &amp; Principe (+239)</option>
                    <option data-countryCode="SA" value="966">Saudi Arabia (+966)</option>
                    <option data-countryCode="SN" value="221">Senegal (+221)</option>
                    <option data-countryCode="CS" value="381">Serbia (+381)</option>
                    <option data-countryCode="SC" value="248">Seychelles (+248)</option>
                    <option data-countryCode="SL" value="232">Sierra Leone (+232)</option>
                    <option data-countryCode="SG" value="65">Singapore (+65)</option>
                    <option data-countryCode="SK" value="421">Slovak Republic (+421)</option>
                    <option data-countryCode="SI" value="386">Slovenia (+386)</option>
                    <option data-countryCode="SB" value="677">Solomon Islands (+677)</option>
                    <option data-countryCode="SO" value="252">Somalia (+252)</option>
                    <option data-countryCode="ZA" value="27">South Africa (+27)</option>
                    <option data-countryCode="ES" value="34">Spain (+34)</option>
                    <option data-countryCode="LK" value="94">Sri Lanka (+94)</option>
                    <option data-countryCode="SH" value="290">St. Helena (+290)</option>
                    <option data-countryCode="KN" value="1869">St. Kitts (+1869)</option>
                    <option data-countryCode="SC" value="1758">St. Lucia (+1758)</option>
                    <option data-countryCode="SD" value="249">Sudan (+249)</option>
                    <option data-countryCode="SR" value="597">Suriname (+597)</option>
                    <option data-countryCode="SZ" value="268">Swaziland (+268)</option>
                    <option data-countryCode="SE" value="46">Sweden (+46)</option>
                    <option data-countryCode="CH" value="41">Switzerland (+41)</option>
                    <option data-countryCode="SI" value="963">Syria (+963)</option>
                    <option data-countryCode="TW" value="886">Taiwan (+886)</option>
                    <option data-countryCode="TJ" value="7">Tajikstan (+7)</option>
                    <option data-countryCode="TH" value="66">Thailand (+66)</option>
                    <option data-countryCode="TG" value="228">Togo (+228)</option>
                    <option data-countryCode="TO" value="676">Tonga (+676)</option>
                    <option data-countryCode="TT" value="1868">Trinidad &amp; Tobago (+1868)</option>
                    <option data-countryCode="TN" value="216">Tunisia (+216)</option>
                    <option data-countryCode="TR" value="90">Turkey (+90)</option>
                    <option data-countryCode="TM" value="7">Turkmenistan (+7)</option>
                    <option data-countryCode="TM" value="993">Turkmenistan (+993)</option>
                    <option data-countryCode="TC" value="1649">Turks &amp; Caicos Islands (+1649)</option>
                    <option data-countryCode="TV" value="688">Tuvalu (+688)</option>
                    <option data-countryCode="UG" value="256">Uganda (+256)</option>
                    <!-- <option data-countryCode="GB" value="44">UK (+44)</option> -->
                    <option data-countryCode="UA" value="380">Ukraine (+380)</option>
                    <option data-countryCode="AE" value="971">United Arab Emirates (+971)</option>
                    <option data-countryCode="UY" value="598">Uruguay (+598)</option>
                    <!-- <option data-countryCode="US" value="1">USA (+1)</option> -->
                    <option data-countryCode="UZ" value="7">Uzbekistan (+7)</option>
                    <option data-countryCode="VU" value="678">Vanuatu (+678)</option>
                    <option data-countryCode="VA" value="379">Vatican City (+379)</option>
                    <option data-countryCode="VE" value="58">Venezuela (+58)</option>
                    <option data-countryCode="VN" value="84">Vietnam (+84)</option>
                    <option data-countryCode="VG" value="84">Virgin Islands - British (+1284)</option>
                    <option data-countryCode="VI" value="84">Virgin Islands - US (+1340)</option>
                    <option data-countryCode="WF" value="681">Wallis &amp; Futuna (+681)</option>
                    <option data-countryCode="YE" value="969">Yemen (North)(+969)</option>
                    <option data-countryCode="YE" value="967">Yemen (South)(+967)</option>
                    <option data-countryCode="ZM" value="260">Zambia (+260)</option>
                    <option data-countryCode="ZW" value="263">Zimbabwe (+263)</option>
                </optgroup>
                </select>
            </article>

            <article>
                <label for=""> Country <sup>*</sup></label>
                <select name="country"  required>
                <option value="">Select Country</option>
                <option value="Afghanistan">Afghanistan</option>
                <option value="Åland Islands">Åland Islands</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="Antarctica">Antarctica</option>
                <option value="Antigua and Barbuda">Antigua and 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="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
                <option value="Botswana">Botswana</option>
                <option value="Bouvet Island">Bouvet Island</option>
                <option value="Brazil">Brazil</option>
                <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
                <option value="Brunei Darussalam">Brunei Darussalam</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="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="Chile">Chile</option>
                <option value="China">China</option>
                <option value="Christmas Island">Christmas Island</option>
                <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
                <option value="Colombia">Colombia</option>
                <option value="Comoros">Comoros</option>
                <option value="Congo">Congo</option>
                <option value="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</option>
                <option value="Cook Islands">Cook Islands</option>
                <option value="Costa Rica">Costa Rica</option>
                <option value="Cote D'ivoire">Cote D'ivoire</option>
                <option value="Croatia">Croatia</option>
                <option value="Cuba">Cuba</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="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 (Malvinas)">Falkland Islands (Malvinas)</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 Territories">French Southern Territories</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="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="Guernsey">Guernsey</option>
                <option value="Guinea">Guinea</option>
                <option value="Guinea-bissau">Guinea-bissau</option>
                <option value="Guyana">Guyana</option>
                <option value="Haiti">Haiti</option>
                <option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>
                <option value="Holy See (Vatican City State)">Holy See (Vatican City State)</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, Islamic Republic of">Iran, Islamic Republic of</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="Jersey">Jersey</option>
                <option value="Jordan">Jordan</option>
                <option value="Kazakhstan">Kazakhstan</option>
                <option value="Kenya">Kenya</option>
                <option value="Kiribati">Kiribati</option>
                <option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
                <option value="Korea, Republic of">Korea, Republic of</option>
                <option value="Kuwait">Kuwait</option>
                <option value="Kyrgyzstan">Kyrgyzstan</option>
                <option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
                <option value="Latvia">Latvia</option>
                <option value="Lebanon">Lebanon</option>
                <option value="Lesotho">Lesotho</option>
                <option value="Liberia">Liberia</option>
                <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
                <option value="Liechtenstein">Liechtenstein</option>
                <option value="Lithuania">Lithuania</option>
                <option value="Luxembourg">Luxembourg</option>
                <option value="Macao">Macao</option>
                <option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</option>
                <option value="Madagascar">Madagascar</option>
                <option value="Malawi">Malawi</option>
                <option value="Malaysia">Malaysia</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="Micronesia, Federated States of">Micronesia, Federated States of</option>
                <option value="Moldova, Republic of">Moldova, Republic of</option>
                <option value="Monaco">Monaco</option>
                <option value="Mongolia">Mongolia</option>
                <option value="Montenegro">Montenegro</option>
                <option value="Montserrat">Montserrat</option>
                <option value="Morocco">Morocco</option>
                <option value="Mozambique">Mozambique</option>
                <option value="Myanmar">Myanmar</option>
                <option value="Namibia">Namibia</option>
                <option value="Nauru">Nauru</option>
                <option value="Nepal">Nepal</option>
                <option value="Netherlands">Netherlands</option>
                <option value="Netherlands Antilles">Netherlands Antilles</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="Northern Mariana Islands">Northern Mariana Islands</option>
                <option value="Norway">Norway</option>
                <option value="Oman">Oman</option>
                <option value="Pakistan">Pakistan</option>
                <option value="Palau">Palau</option>
                <option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</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="Philippines">Philippines</option>
                <option value="Pitcairn">Pitcairn</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="Reunion">Reunion</option>
                <option value="Romania">Romania</option>
                <option value="Russian Federation">Russian Federation</option>
                <option value="Rwanda">Rwanda</option>
                <option value="Saint Helena">Saint Helena</option>
                <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
                <option value="Saint Lucia">Saint Lucia</option>
                <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
                <option value="Saint Vincent and The Grenadines">Saint Vincent and The Grenadines</option>
                <option value="Samoa">Samoa</option>
                <option value="San Marino">San Marino</option>
                <option value="Sao Tome and Principe">Sao Tome and 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="South Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</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="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
                <option value="Swaziland">Swaziland</option>
                <option value="Sweden">Sweden</option>
                <option value="Switzerland">Switzerland</option>
                <option value="Syrian Arab Republic">Syrian Arab Republic</option>
                <option value="Taiwan">Taiwan</option>
                <option value="Tajikistan">Tajikistan</option>
                <option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
                <option value="Thailand">Thailand</option>
                <option value="Timor-leste">Timor-leste</option>
                <option value="Togo">Togo</option>
                <option value="Tokelau">Tokelau</option>
                <option value="Tonga">Tonga</option>
                <option value="Trinidad and Tobago">Trinidad and Tobago</option>
                <option value="Tunisia">Tunisia</option>
                <option value="Turkey">Turkey</option>
                <option value="Turkmenistan">Turkmenistan</option>
                <option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
                <option value="Tuvalu">Tuvalu</option>
                <option value="Uganda">Uganda</option>
                <option value="Ukraine">Ukraine</option>
                <option value="United Arab Emirates">United Arab Emirates</option>
                <option value="United Kingdom">United Kingdom</option>
                <option value="United States">United States</option>
                <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
                <option value="Uruguay">Uruguay</option>
                <option value="Uzbekistan">Uzbekistan</option>
                <option value="Vanuatu">Vanuatu</option>
                <option value="Venezuela">Venezuela</option>
                <option value="Viet Nam">Viet Nam</option>
                <option value="Virgin Islands, British">Virgin Islands, British</option>
                <option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
                <option value="Wallis and Futuna">Wallis and Futuna</option>
                <option value="Western Sahara">Western Sahara</option>
                <option value="Yemen">Yemen</option>
                <option value="Zambia">Zambia</option>
                <option value="Zimbabwe">Zimbabwe</option>
                </select>
        </article>

        <article>
            <label for="">Phone Number <sup>*</sup></label>
            <input type="text" name='phone_number' required>
        </article>
        </div>

        
        <div class="input-grid">
            <article>
                <label for="">Year (DOB)<sup>*</sup></label>
                <input type="number" name='year' placeholder='1980' required>
            </article>

            <article>
                <label for="">Month (DOB)<sup>*</sup></label>
                <input type="text" name='month' placeholder='<?php echo date('M')?>' required>
            </article>

            <article>
                <label for="">Day (DOB)<sup>*</sup></label>
                <input type="number" name='day' placeholder='<?php echo date('d')?>' required>
            </article>
        </div>

        <button type='submit' name='submit'>Next</button>
        </form>
       </div>
 </div>

 <br><br><br>


<?php  include "../includes/footer.php"; ?>
