partners.betcasa.com
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urlscan Pro
20.67.211.68
Public Scan
URL:
https://partners.betcasa.com/registration.asp
Submission: On February 12 via api from DE — Scanned from DE
Submission: On February 12 via api from DE — Scanned from DE
Form analysis 1 forms found in the DOM
Name: registrationform — POST
<form method="POST" name="registrationform" id="registrationform" autocomplete="off" class="secure form-horizontal" novalidate="novalidate" accept-charset="iso-8859-1">
<div class="widget">
<div class="widget-container col-md-6 col-md-push-2">
<div class="main-header">
<h2>Registration Form</h2>
<em></em>
</div>
<div class="wizard-wrapper" style="width: 800px;">
<!-- wizard progress bar -->
<div id="demo-wizard" class="wizard">
<ul class="steps">
<li id="progress-block1" class="active"><span class="badge badge-info">1</span>PERSONAL<span class="chevron"></span></li>
<li id="progress-block2"><span class="badge">2</span>PAYMENTS<span class="chevron"></span></li>
<li id="progress-block3" class="last"><span class="badge">3</span>ADDITIONAL<span class="chevron"></span></li>
</ul>
</div>
<!-- panel 1 -->
<div class="wizardpanel block1 show" id="block1">
<div class="row">
<h3>Personal Details</h3>
<div class="form-group has-feedback"><label for="username" class="control-label col-xs-2">Username </label>
<div class="input-group col-xs-10"><input name="username" id="username" type="text" value="" required="true" class="{required:true,messages:{required:'Please check the username entered.'}}" allowedstring="true" 4"="" maxlength="140"
size="40"><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="password" class="control-label col-xs-2">Password </label>
<div class="input-group col-xs-10"><input name="password" id="password" type="password" value="" required="true" class="{required:true,messages:{required:'Please check the password entered.'}}" ispassword="true" checkspecialchar="true"
checkmaxchars="20" autocomplete="off" maxlength="21" size="20" onkeyup="testPassword(this.value);" minlength="6"><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="passwordretype" class="control-label col-xs-2">Re-Type Password </label>
<div class="input-group col-xs-10"><input name="passwordretype" id="passwordretype" type="password" value="" required="true" class="{required:true,messages:{required:'Please check the password entered.'}}" maxlength="20"
autocomplete="off" size="20" minlength="6"><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group">
<div class="col-xs-2"></div>
<div id="passtestindicator" class="col-xs-10"></div>
</div>
<div class="form-group">
<div class="col-xs-2"></div>
<div id="passtestindicator" class="col-xs-10"><img src="includes/dynamimg.asp" alt="This Is verification Image"></div>
</div>
<div class="form-group has-feedback"><label for="verificationimg" class="control-label col-xs-2">Please enter the text as it appears in the image above. </label>
<div class="input-group col-xs-10"><input name="verificationimg" id="verificationimg" type="text" value="" required="true" class="{required:true,messages:{required:'jscheckverificationimg'}}" maxlength="8" size="10" minlength=""><span
class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="securityquestion" class="control-label col-xs-2">Select a security question </label>
<div class="input-group col-xs-10"><select name="securityquestion" id="securityquestion">
<option value=""></option>
<option value="Your first pet's name">Your first pet's name</option>
</select><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="securityquestioncustom" class="control-label col-xs-2">OR enter your own security question </label>
<div class="input-group col-xs-10"><input name="securityquestioncustom" id="securityquestioncustom" type="text" value="" maxlength="50" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="securityanswer" class="control-label col-xs-2">Security Question Answer </label>
<div class="input-group col-xs-10"><input name="securityanswer" id="securityanswer" type="text" value="" securityquestions2="true" maxlength="50" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<h3>Contact Details</h3>
<div class="form-group has-feedback"><label for="emailaddress" class="control-label col-xs-2">Email Address </label>
<div class="input-group col-xs-10"><input name="emailaddress" id="emailaddress" type="text" value="" required="true" class="{required:true,messages:{required:'Please check your Email Address'}}" email="true" maxlength="140" size="40"
minlength=""><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="confirmemail" class="control-label col-xs-2">Re-enter Email </label>
<div class="input-group col-xs-10"><input name="confirmemail" id="confirmemail" type="text" value="" required="true" class="{required:true,messages:{required:'Please check your Email Address'}}" email="true" equalto="#emailaddress"
maxlength="140" size="40" minlength=""><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="firstname" class="control-label col-xs-2">First Name </label>
<div class="input-group col-xs-10"><input name="firstname" id="firstname" type="text" value="" required="true" class="{required:true,messages:{required:'Please check your first name'}}" alphanumeric="true" maxlength="140" size="40"
minlength=""><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="lastname" class="control-label col-xs-2">Last Name </label>
<div class="input-group col-xs-10"><input name="lastname" id="lastname" type="text" value="" required="true" class="{required:true,messages:{required:'Please check your last name'}}" alphanumeric="true" maxlength="140" size="40"
minlength=""><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="companyname" class="control-label col-xs-2">Company Name </label>
<div class="input-group col-xs-10"><input name="companyname" id="companyname" type="text" value="" alphanumeric="true" maxlength="140" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="phone" class="control-label col-xs-2">Contact Phone </label>
<div class="input-group col-xs-10"><input name="phone" id="phone" type="text" value="" isphone="true" maxlength="20" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="cellphone" class="control-label col-xs-2">Cell Phone </label>
<div class="input-group col-xs-10"><input name="cellphone" id="cellphone" type="text" value="" isphone="true" maxlength="20" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="imname" class="control-label col-xs-2">IM name </label>
<div class="input-group col-xs-10"><input name="imname" id="imname" type="text" value="" allowedstring="true" maxlength="100" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="skypename" class="control-label col-xs-2">Skype Name </label>
<div class="input-group col-xs-10"><input name="skypename" id="skypename" type="text" value=""="true"="" maxlength="100" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="address1" class="control-label col-xs-2">Address 1 </label>
<div class="input-group col-xs-10"><input name="address1" id="address1" type="text" value="" allowedstring="true" maxlength="250" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="address2" class="control-label col-xs-2">City </label>
<div class="input-group col-xs-10"><input name="address2" id="address2" type="text" value="" maxlength="250" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="state" class="control-label col-xs-2">State </label>
<div class="input-group col-xs-10"><input name="state" id="state" type="text" value="" allowedstring="true" maxlength="250" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="zip" class="control-label col-xs-2">Zip </label>
<div class="input-group col-xs-10"><input name="zip" id="zip" type="text" value="" allowedstring="true" maxlength="250" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="country" class="control-label col-xs-2">Country </label>
<div class="input-group col-xs-10"><select size="1" id="country" name="country">
<option value=""></option>
<option value="ÅLAND ISLANDS" isocountrycode="ALA">ÅLAND ISLANDS</option>
<option value="AFGHANISTAN" isocountrycode="AFG">AFGHANISTAN</option>
<option value="ALBANIA" isocountrycode="ALB">ALBANIA</option>
<option value="ALGERIA" isocountrycode="DZA">ALGERIA</option>
<option value="AMERICAN SAMOA" isocountrycode="ASM">AMERICAN SAMOA</option>
<option value="ANDORRA" isocountrycode="AND">ANDORRA</option>
<option value="ANGOLA" isocountrycode="AGO">ANGOLA</option>
<option value="ANGUILLA" isocountrycode="AIA">ANGUILLA</option>
<option value="ANTARCTICA" isocountrycode="ATA">ANTARCTICA</option>
<option value="ANTIGUA AND BARBUDA" isocountrycode="ATG">ANTIGUA AND BARBUDA</option>
<option value="ARGENTINA" isocountrycode="ARG">ARGENTINA</option>
<option value="ARMENIA" isocountrycode="ARM">ARMENIA</option>
<option value="ARUBA" isocountrycode="ABW">ARUBA</option>
<option value="AUSTRALIA" isocountrycode="AUS">AUSTRALIA</option>
<option value="AUSTRIA" isocountrycode="AUT">AUSTRIA</option>
<option value="AZERBAIJAN" isocountrycode="AZE">AZERBAIJAN</option>
<option value="BAHAMAS" isocountrycode="BHS">BAHAMAS</option>
<option value="BAHRAIN" isocountrycode="BHR">BAHRAIN</option>
<option value="BANGLADESH" isocountrycode="BGD">BANGLADESH</option>
<option value="BARBADOS" isocountrycode="BRB">BARBADOS</option>
<option value="BELARUS" isocountrycode="BLR">BELARUS</option>
<option value="BELGIUM" isocountrycode="BEL">BELGIUM</option>
<option value="BELIZE" isocountrycode="BLZ">BELIZE</option>
<option value="BENIN" isocountrycode="BEN">BENIN</option>
<option value="BERMUDA" isocountrycode="BMU">BERMUDA</option>
<option value="BHUTAN" isocountrycode="BTN">BHUTAN</option>
<option value="BOLIVIA (PLURINATIONAL STATE OF)" isocountrycode="BOL">BOLIVIA (PLURINATIONAL STATE OF)</option>
<option value="BONAIRE. SINT EUSTATIUS AND SABA" isocountrycode="BES">BONAIRE. SINT EUSTATIUS AND SABA</option>
<option value="BOSNIA AND HERZEGOVINA" isocountrycode="BIH">BOSNIA AND HERZEGOVINA</option>
<option value="BOTSWANA" isocountrycode="BWA">BOTSWANA</option>
<option value="BOUVET ISLAND" isocountrycode="BVT">BOUVET ISLAND</option>
<option value="BRAZIL" isocountrycode="BRA">BRAZIL</option>
<option value="BRITISH INDIAN OCEAN TERRITORY" isocountrycode="IOT">BRITISH INDIAN OCEAN TERRITORY</option>
<option value="BRUNEI DARUSSALAM" isocountrycode="BRN">BRUNEI DARUSSALAM</option>
<option value="BULGARIA" isocountrycode="BGR">BULGARIA</option>
<option value="BURKINA FASO" isocountrycode="BFA">BURKINA FASO</option>
<option value="BURUNDI" isocountrycode="BDI">BURUNDI</option>
<option value="CôTE D'IVOIRE" isocountrycode="CIV">CôTE D'IVOIRE</option>
<option value="CABO VERDE" isocountrycode="CPV">CABO VERDE</option>
<option value="CAMBODIA" isocountrycode="KHM">CAMBODIA</option>
<option value="CAMEROON" isocountrycode="CMR">CAMEROON</option>
<option value="CANADA" isocountrycode="CAN">CANADA</option>
<option value="CAYMAN ISLANDS" isocountrycode="CYM">CAYMAN ISLANDS</option>
<option value="CENTRAL AFRICAN REPUBLIC" isocountrycode="CAF">CENTRAL AFRICAN REPUBLIC</option>
<option value="CHAD" isocountrycode="TCD">CHAD</option>
<option value="CHILE" isocountrycode="CHL">CHILE</option>
<option value="CHINA" isocountrycode="CHN">CHINA</option>
<option value="CHRISTMAS ISLAND" isocountrycode="CXR">CHRISTMAS ISLAND</option>
<option value="COCOS (KEELING) ISLANDS" isocountrycode="CCK">COCOS (KEELING) ISLANDS</option>
<option value="COLOMBIA" isocountrycode="COL">COLOMBIA</option>
<option value="COMOROS" isocountrycode="COM">COMOROS</option>
<option value="CONGO" isocountrycode="COG">CONGO</option>
<option value="CONGO (DEMOCRATIC REPUBLIC OF THE)" isocountrycode="COD">CONGO (DEMOCRATIC REPUBLIC OF THE)</option>
<option value="COOK ISLANDS" isocountrycode="COK">COOK ISLANDS</option>
<option value="COSTA RICA" isocountrycode="CRI">COSTA RICA</option>
<option value="CROATIA" isocountrycode="HRV">CROATIA</option>
<option value="CUBA" isocountrycode="CUB">CUBA</option>
<option value="CURAÇAO" isocountrycode="CUW">CURAÇAO</option>
<option value="CYPRUS" isocountrycode="CYP">CYPRUS</option>
<option value="CZECHIA" isocountrycode="CZE">CZECHIA</option>
<option value="DENMARK" isocountrycode="DNK">DENMARK</option>
<option value="DJIBOUTI" isocountrycode="DJI">DJIBOUTI</option>
<option value="DOMINICA" isocountrycode="DMA">DOMINICA</option>
<option value="DOMINICAN REPUBLIC" isocountrycode="DOM">DOMINICAN REPUBLIC</option>
<option value="ECUADOR" isocountrycode="ECU">ECUADOR</option>
<option value="EGYPT" isocountrycode="EGY">EGYPT</option>
<option value="EL SALVADOR" isocountrycode="SLV">EL SALVADOR</option>
<option value="EQUATORIAL GUINEA" isocountrycode="GNQ">EQUATORIAL GUINEA</option>
<option value="ERITREA" isocountrycode="ERI">ERITREA</option>
<option value="ESTONIA" isocountrycode="EST">ESTONIA</option>
<option value="ETHIOPIA" isocountrycode="ETH">ETHIOPIA</option>
<option value="FALKLAND ISLANDS (MALVINAS)" isocountrycode="FLK">FALKLAND ISLANDS (MALVINAS)</option>
<option value="FAROE ISLANDS" isocountrycode="FRO">FAROE ISLANDS</option>
<option value="FIJI" isocountrycode="FJI">FIJI</option>
<option value="FINLAND" isocountrycode="FIN">FINLAND</option>
<option value="FRANCE" isocountrycode="FRA">FRANCE</option>
<option value="FRENCH GUIANA" isocountrycode="GUF">FRENCH GUIANA</option>
<option value="FRENCH POLYNESIA" isocountrycode="PYF">FRENCH POLYNESIA</option>
<option value="FRENCH SOUTHERN TERRITORIES" isocountrycode="ATF">FRENCH SOUTHERN TERRITORIES</option>
<option value="GABON" isocountrycode="GAB">GABON</option>
<option value="GAMBIA" isocountrycode="GMB">GAMBIA</option>
<option value="GEORGIA" isocountrycode="GEO">GEORGIA</option>
<option value="GERMANY" isocountrycode="DEU">GERMANY</option>
<option value="GHANA" isocountrycode="GHA">GHANA</option>
<option value="GIBRALTAR" isocountrycode="GIB">GIBRALTAR</option>
<option value="GREECE" isocountrycode="GRC">GREECE</option>
<option value="GREENLAND" isocountrycode="GRL">GREENLAND</option>
<option value="GRENADA" isocountrycode="GRD">GRENADA</option>
<option value="GUADELOUPE" isocountrycode="GLP">GUADELOUPE</option>
<option value="GUAM" isocountrycode="GUM">GUAM</option>
<option value="GUATEMALA" isocountrycode="GTM">GUATEMALA</option>
<option value="GUERNSEY" isocountrycode="GGY">GUERNSEY</option>
<option value="GUINEA" isocountrycode="GIN">GUINEA</option>
<option value="GUINEA-BISSAU" isocountrycode="GNB">GUINEA-BISSAU</option>
<option value="GUYANA" isocountrycode="GUY">GUYANA</option>
<option value="HAITI" isocountrycode="HTI">HAITI</option>
<option value="HEARD ISLAND AND MCDONALD ISLA" isocountrycode="HMD">HEARD ISLAND AND MCDONALD ISLA</option>
<option value="HOLY SEE" isocountrycode="VAT">HOLY SEE</option>
<option value="HONDURAS" isocountrycode="HND">HONDURAS</option>
<option value="HONG KONG" isocountrycode="HKG">HONG KONG</option>
<option value="HUNGARY" isocountrycode="HUN">HUNGARY</option>
<option value="ICELAND" isocountrycode="ISL">ICELAND</option>
<option value="INDIA" isocountrycode="IND">INDIA</option>
<option value="INDONESIA" isocountrycode="IDN">INDONESIA</option>
<option value="IRAN (ISLAMIC REPUBLIC OF)" isocountrycode="IRN">IRAN (ISLAMIC REPUBLIC OF)</option>
<option value="IRAQ" isocountrycode="IRQ">IRAQ</option>
<option value="IRELAND" isocountrycode="IRL">IRELAND</option>
<option value="ISLE OF MAN" isocountrycode="IMN">ISLE OF MAN</option>
<option value="ISRAEL" isocountrycode="ISR">ISRAEL</option>
<option value="ITALY" isocountrycode="ITA">ITALY</option>
<option value="JAMAICA" isocountrycode="JAM">JAMAICA</option>
<option value="JAPAN" isocountrycode="JPN">JAPAN</option>
<option value="JERSEY" isocountrycode="JEY">JERSEY</option>
<option value="JORDAN" isocountrycode="JOR">JORDAN</option>
<option value="KAZAKHSTAN" isocountrycode="KAZ">KAZAKHSTAN</option>
<option value="KENYA" isocountrycode="KEN">KENYA</option>
<option value="KIRIBATI" isocountrycode="KIR">KIRIBATI</option>
<option value="KOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF)" isocountrycode="PRK">KOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF)</option>
<option value="KOREA (REPUBLIC OF)" isocountrycode="KOR">KOREA (REPUBLIC OF)</option>
<option value="KUWAIT" isocountrycode="KWT">KUWAIT</option>
<option value="KYRGYZSTAN" isocountrycode="KGZ">KYRGYZSTAN</option>
<option value="LAO PEOPLE'S DEMOCRATIC REPUBLIC" isocountrycode="LAO">LAO PEOPLE'S DEMOCRATIC REPUBLIC</option>
<option value="LATVIA" isocountrycode="LVA">LATVIA</option>
<option value="LEBANON" isocountrycode="LBN">LEBANON</option>
<option value="LESOTHO" isocountrycode="LSO">LESOTHO</option>
<option value="LIBERIA" isocountrycode="LBR">LIBERIA</option>
<option value="LIBYA" isocountrycode="LBY">LIBYA</option>
<option value="LIECHTENSTEIN" isocountrycode="LIE">LIECHTENSTEIN</option>
<option value="LITHUANIA" isocountrycode="LTU">LITHUANIA</option>
<option value="LUXEMBOURG" isocountrycode="LUX">LUXEMBOURG</option>
<option value="MACAO" isocountrycode="MAC">MACAO</option>
<option value="MACEDONIA (THE FORMER YUGOSLAV REPUBLIC OF)" isocountrycode="MKD">MACEDONIA (THE FORMER YUGOSLAV REPUBLIC OF)</option>
<option value="MADAGASCAR" isocountrycode="MDG">MADAGASCAR</option>
<option value="MALAWI" isocountrycode="MWI">MALAWI</option>
<option value="MALAYSIA" isocountrycode="MYS">MALAYSIA</option>
<option value="MALDIVES" isocountrycode="MDV">MALDIVES</option>
<option value="MALI" isocountrycode="MLI">MALI</option>
<option value="MALTA" isocountrycode="MLT">MALTA</option>
<option value="MARSHALL ISLANDS" isocountrycode="MHL">MARSHALL ISLANDS</option>
<option value="MARTINIQUE" isocountrycode="MTQ">MARTINIQUE</option>
<option value="MAURITANIA" isocountrycode="MRT">MAURITANIA</option>
<option value="MAURITIUS" isocountrycode="MUS">MAURITIUS</option>
<option value="MAYOTTE" isocountrycode="MYT">MAYOTTE</option>
<option value="MEXICO" isocountrycode="MEX">MEXICO</option>
<option value="MICRONESIA (FEDERATED STATES OF)" isocountrycode="FSM">MICRONESIA (FEDERATED STATES OF)</option>
<option value="MOLDOVA (REPUBLIC OF)" isocountrycode="MDA">MOLDOVA (REPUBLIC OF)</option>
<option value="MONACO" isocountrycode="MCO">MONACO</option>
<option value="MONGOLIA" isocountrycode="MNG">MONGOLIA</option>
<option value="MONTENEGRO" isocountrycode="MNE">MONTENEGRO</option>
<option value="MONTSERRAT" isocountrycode="MSR">MONTSERRAT</option>
<option value="MOROCCO" isocountrycode="MAR">MOROCCO</option>
<option value="MOZAMBIQUE" isocountrycode="MOZ">MOZAMBIQUE</option>
<option value="MYANMAR" isocountrycode="MMR">MYANMAR</option>
<option value="NAMIBIA" isocountrycode="NAM">NAMIBIA</option>
<option value="NAURU" isocountrycode="NRU">NAURU</option>
<option value="NEPAL" isocountrycode="NPL">NEPAL</option>
<option value="NETHERLANDS" isocountrycode="NLD">NETHERLANDS</option>
<option value="NETHERLANDS ANTILLES" isocountrycode="ANT">NETHERLANDS ANTILLES</option>
<option value="NEW CALEDONIA" isocountrycode="NCL">NEW CALEDONIA</option>
<option value="NEW ZEALAND" isocountrycode="NZL">NEW ZEALAND</option>
<option value="NICARAGUA" isocountrycode="NIC">NICARAGUA</option>
<option value="NIGER" isocountrycode="NER">NIGER</option>
<option value="NIGERIA" isocountrycode="NGA">NIGERIA</option>
<option value="NIUE" isocountrycode="NIU">NIUE</option>
<option value="NORFOLK ISLAND" isocountrycode="NFK">NORFOLK ISLAND</option>
<option value="NORTHERN MARIANA ISLANDS" isocountrycode="MNP">NORTHERN MARIANA ISLANDS</option>
<option value="NORWAY" isocountrycode="NOR">NORWAY</option>
<option value="OMAN" isocountrycode="OMN">OMAN</option>
<option value="PAKISTAN" isocountrycode="PAK">PAKISTAN</option>
<option value="PALAU" isocountrycode="PLW">PALAU</option>
<option value="PALESTINE. STATE OF" isocountrycode="PSE">PALESTINE. STATE OF</option>
<option value="PANAMA" isocountrycode="PAN">PANAMA</option>
<option value="PAPUA NEW GUINEA" isocountrycode="PNG">PAPUA NEW GUINEA</option>
<option value="PARAGUAY" isocountrycode="PRY">PARAGUAY</option>
<option value="PERU" isocountrycode="PER">PERU</option>
<option value="PHILIPPINES" isocountrycode="PHL">PHILIPPINES</option>
<option value="PITCAIRN" isocountrycode="PCN">PITCAIRN</option>
<option value="POLAND" isocountrycode="POL">POLAND</option>
<option value="PORTUGAL" isocountrycode="PRT">PORTUGAL</option>
<option value="PUERTO RICO" isocountrycode="PRI">PUERTO RICO</option>
<option value="QATAR" isocountrycode="QAT">QATAR</option>
<option value="RÉUNION" isocountrycode="REU">RÉUNION</option>
<option value="ROMANIA" isocountrycode="ROU">ROMANIA</option>
<option value="RUSSIAN FEDERATION" isocountrycode="RUS">RUSSIAN FEDERATION</option>
<option value="RWANDA" isocountrycode="RWA">RWANDA</option>
<option value="SAINT BARTHÉLEMY" isocountrycode="BLM">SAINT BARTHÉLEMY</option>
<option value="SAINT HELENA. ASCENSION AND TRISTAN DA CUNHA" isocountrycode="SHN">SAINT HELENA. ASCENSION AND TRISTAN DA CUNHA</option>
<option value="SAINT KITTS AND NEVIS" isocountrycode="KNA">SAINT KITTS AND NEVIS</option>
<option value="SAINT LUCIA" isocountrycode="LCA">SAINT LUCIA</option>
<option value="SAINT MARTIN (FRENCH PART)" isocountrycode="MAF">SAINT MARTIN (FRENCH PART)</option>
<option value="SAINT PIERRE AND MIQUELON" isocountrycode="SPM">SAINT PIERRE AND MIQUELON</option>
<option value="SAINT VINCENT AND THE GRENADIN" isocountrycode="VCT">SAINT VINCENT AND THE GRENADIN</option>
<option value="SAMOA" isocountrycode="WSM">SAMOA</option>
<option value="SAN MARINO" isocountrycode="SMR">SAN MARINO</option>
<option value="SAO TOME AND PRINCIPE" isocountrycode="STP">SAO TOME AND PRINCIPE</option>
<option value="SAUDI ARABIA" isocountrycode="SAU">SAUDI ARABIA</option>
<option value="SENEGAL" isocountrycode="SEN">SENEGAL</option>
<option value="SERBIA" isocountrycode="SRB">SERBIA</option>
<option value="SEYCHELLES" isocountrycode="SYC">SEYCHELLES</option>
<option value="SIERRA LEONE" isocountrycode="SLE">SIERRA LEONE</option>
<option value="SINGAPORE" isocountrycode="SGP">SINGAPORE</option>
<option value="SINT MAARTEN (DUTCH PART)" isocountrycode="SXM">SINT MAARTEN (DUTCH PART)</option>
<option value="SLOVAKIA" isocountrycode="SVK">SLOVAKIA</option>
<option value="SLOVENIA" isocountrycode="SVN">SLOVENIA</option>
<option value="SOLOMON ISLANDS" isocountrycode="SLB">SOLOMON ISLANDS</option>
<option value="SOMALIA" isocountrycode="SOM">SOMALIA</option>
<option value="SOUTH AFRICA" isocountrycode="ZAF">SOUTH AFRICA</option>
<option value="SOUTH GEORGIA AND THE SOUTH SA" isocountrycode="SGS">SOUTH GEORGIA AND THE SOUTH SA</option>
<option value="SOUTH SUDAN" isocountrycode="SSD">SOUTH SUDAN</option>
<option value="SPAIN" isocountrycode="ESP">SPAIN</option>
<option value="SRI LANKA" isocountrycode="LKA">SRI LANKA</option>
<option value="SUDAN" isocountrycode="SDN">SUDAN</option>
<option value="SURINAME" isocountrycode="SUR">SURINAME</option>
<option value="SVALBARD AND JAN MAYEN" isocountrycode="SJM">SVALBARD AND JAN MAYEN</option>
<option value="SWAZILAND" isocountrycode="SWZ">SWAZILAND</option>
<option value="SWEDEN" isocountrycode="SWE">SWEDEN</option>
<option value="SWITZERLAND" isocountrycode="CHE">SWITZERLAND</option>
<option value="SYRIAN ARAB REPUBLIC" isocountrycode="SYR">SYRIAN ARAB REPUBLIC</option>
<option value="TAIWAN" isocountrycode="TWN">TAIWAN</option>
<option value="TAJIKISTAN" isocountrycode="TJK">TAJIKISTAN</option>
<option value="TANZANIA, UNITED REPUBLIC OF" isocountrycode="TZA">TANZANIA, UNITED REPUBLIC OF</option>
<option value="THAILAND" isocountrycode="THA">THAILAND</option>
<option value="TIMOR-LESTE" isocountrycode="TLS">TIMOR-LESTE</option>
<option value="TOGO" isocountrycode="TGO">TOGO</option>
<option value="TOKELAU" isocountrycode="TKL">TOKELAU</option>
<option value="TONGA" isocountrycode="TON">TONGA</option>
<option value="TRINIDAD AND TOBAGO" isocountrycode="TTO">TRINIDAD AND TOBAGO</option>
<option value="TUNISIA" isocountrycode="TUN">TUNISIA</option>
<option value="TURKEY" isocountrycode="TUR">TURKEY</option>
<option value="TURKMENISTAN" isocountrycode="TKM">TURKMENISTAN</option>
<option value="TURKS AND CAICOS ISLANDS" isocountrycode="TCA">TURKS AND CAICOS ISLANDS</option>
<option value="TUVALU" isocountrycode="TUV">TUVALU</option>
<option value="UGANDA" isocountrycode="UGA">UGANDA</option>
<option value="UKRAINE" isocountrycode="UKR">UKRAINE</option>
<option value="UNITED ARAB EMIRATES" isocountrycode="ARE">UNITED ARAB EMIRATES</option>
<option value="UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND" isocountrycode="GBR">UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND</option>
<option value="UNITED STATES MINOR OUTLYING I" isocountrycode="UMI">UNITED STATES MINOR OUTLYING I</option>
<option value="UNITED STATES OF AMERICA" isocountrycode="USA">UNITED STATES OF AMERICA</option>
<option value="URUGUAY" isocountrycode="URY">URUGUAY</option>
<option value="UZBEKISTAN" isocountrycode="UZB">UZBEKISTAN</option>
<option value="VANUATU" isocountrycode="VUT">VANUATU</option>
<option value="VENEZUELA (BOLIVARIAN REPUBLIC OF)" isocountrycode="VEN">VENEZUELA (BOLIVARIAN REPUBLIC OF)</option>
<option value="VIET NAM" isocountrycode="VNM">VIET NAM</option>
<option value="VIRGIN ISLANDS (BRITISH)" isocountrycode="VGB">VIRGIN ISLANDS (BRITISH)</option>
<option value="VIRGIN ISLANDS (U.S.)" isocountrycode="VIR">VIRGIN ISLANDS (U.S.)</option>
<option value="WALLIS AND FUTUNA" isocountrycode="WLF">WALLIS AND FUTUNA</option>
<option value="WESTERN SAHARA" isocountrycode="ESH">WESTERN SAHARA</option>
<option value="YEMEN" isocountrycode="YEM">YEMEN</option>
<option value="YUGOSLAVIA" isocountrycode="">YUGOSLAVIA</option>
<option value="ZAMBIA" isocountrycode="ZMB">ZAMBIA</option>
<option value="ZIMBABWE" isocountrycode="ZWE">ZIMBABWE</option>
</select><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
</div>
<div class="row">
<span class="next btn btn-info pull-right" data-current-block="1" data-next-block="2"><i class="fa fa-angle-double-right fa-2x"></i></span>
</div>
</div>
<!-- panel 2-->
<div class="wizardpanel block2 hidden" id="block2">
<div class="row">
<div class="form-group">
<label for="paymentoptionid" class="control-label col-xs-2">Payment Method</label>
<div class="input-group col-xs-8"><select name="paymentoptionid" id="paymentoptionid">
<option value="15|EUR">BANK [EUR]</option>
<option value="5|EUR">NETELLER [EUR]</option>
<option value="14|EUR">Skrill [EUR]</option>
</select></div>
</div>
<div id="paymentmenu_title" class="row">BANK</div>
<div id="paymentmenu_details" class="row"></div>
<div id="paymentmethodcontainer" class="row">
<div class="form-group">
<div class="col-xs-10">Account holder information</div>
</div>
<div class="form-group has-feedback"><label for="bankfirstname" class="control-label col-xs-2">First Name</label>
<div class="input-group col-xs-8"><input type="text" name="bankfirstname" id="bankfirstname" class="{ required: true,messages:{required:'Please enter your firstname'}}" required="true" nocreditcard="true"> <span
class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="banklastname" class="control-label col-xs-2">Last Name</label>
<div class="input-group col-xs-8"><input type="text" name="banklastname" id="banklastname" class="{ required: true,messages:{required:'Please enter your lastsname'}}" required="true" nocreditcard="true"> <span
class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="bankemailaddress" class="control-label col-xs-2">Email Address</label>
<div class="input-group col-xs-8"><input type="text" name="bankemailaddress" id="bankemailaddress" class="{ required: true,messages:{required:'Please enter an Email Address'}}" required="true" email="true" nocreditcard="true"> <span
class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="birthdate" class="control-label col-xs-2">Birthdate (YYYY-MM-DD)</label>
<div class="input-group col-xs-8"><input type="text" name="birthdate" id="birthdate" class="{ required: true,messages:{required:'jscheckBirthdate'}}" required="true" date="true" nocreditcard="true"> <span
class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group">
<div class="col-xs-10">Bank account information</div>
</div>
<div class="form-group has-feedback" style="display: none;"><label for="accountno" class="control-label col-xs-2">Account No</label>
<div class="input-group col-xs-8"><input type="text" name="accountno" id="accountno"
data-countries="CUW,ZWE,ZMB,YEM,ESH,WLF,VIR,VGB,VNM,VEN,VUT,UZB,URY,USA,GBR,UKR,UGA,TUV,TCA,TKM,TTO,TON,TKL,TGO,TLS,THA,TZA,TJK,TWN,SWZ,SJM,SUR,LKA,SGS,ZAF,SOM,SLB,SGP,SLE,SYC,SEN,STP,WSM,VCT,LCA,KNA,SHN,RWA,RUS,PRI,PCN,PHL,PER,PRY,PNG,PAN,PLW,OMN,MNP,NFK,NIU,NGA,NER,NIC,NZL,NCL,ANT,NPL,NAM,MMR,MOZ,MAR,MSR,MNG,FSM,MEX,MHL,MLI,MDV,MYS,MWI,MAC,LBR,LSO,LAO,KOR,KIR,KEN,JEY,JPN,JAM,IMN,IDN,IND,HKG,HND,VAT,HMD,HTI,GUY,GNB,GIN,GGY,GTM,GUM,GRD,GRL,GHA,GMB,GAB,ATF,PYF,FJI,FRO,FLK,ETH,GNQ,SLV,EGY,ECU,DOM,DMA,DJI,DNK,CIV,CRI,COK,COD,COG,COM,COL,CCK,CXR,CHN,CHL,TCD,CAF,CYM,CPV,CAN,CMR,KHM,BDI,BFA,BRN,BRA,BVT,BWA,BOL,BTN,BMU,BEN,BLZ,BRB,BGD,BHS,AUS,ABW,ARM,ARG,ATG,ATA,AIA,AGO,ASM,"
validation-cuw="^.*$" validation-zwe="^.*$" validation-zmb="^.*$" validation-yem="^.*$" validation-esh="^.*$" validation-wlf="^.*$" validation-vir="^.*$" validation-vgb="^.*$" validation-vnm="^.*$" validation-ven="^.*$"
validation-vut="^.*$" validation-uzb="^.*$" validation-ury="^.*$" validation-usa="^.*$" validation-gbr="^.*$" validation-ukr="^.*$" validation-uga="^.*$" validation-tuv="^.*$" validation-tca="^.*$" validation-tkm="^.*$"
validation-tto="^.*$" validation-ton="^.*$" validation-tkl="^.*$" validation-tgo="^.*$" validation-tls="^.*$" validation-tha="^.*$" validation-tza="^.*$" validation-tjk="^.*$" validation-twn="^.*$" validation-swz="^.*$"
validation-sjm="^.*$" validation-sur="^.*$" validation-lka="^.*$" validation-sgs="^.*$" validation-zaf="^.*$" validation-som="^.*$" validation-slb="^.*$" validation-sgp="^.*$" validation-sle="^.*$" validation-syc="^.*$"
validation-sen="^.*$" validation-stp="^.*$" validation-wsm="^.*$" validation-vct="^.*$" validation-lca="^.*$" validation-kna="^.*$" validation-shn="^.*$" validation-rwa="^.*$" validation-rus="^.*$" validation-pri="^.*$"
validation-pcn="^.*$" validation-phl="^.*$" validation-per="^.*$" validation-pry="^.*$" validation-png="^.*$" validation-pan="^.*$" validation-plw="^.*$" validation-omn="^.*$" validation-mnp="^.*$" validation-nfk="^.*$"
validation-niu="^.*$" validation-nga="^.*$" validation-ner="^.*$" validation-nic="^.*$" validation-nzl="^.*$" validation-ncl="^.*$" validation-ant="^.*$" validation-npl="^.*$" validation-nam="^.*$" validation-mmr="^.*$"
validation-moz="^.*$" validation-mar="^.*$" validation-msr="^.*$" validation-mng="^.*$" validation-fsm="^.*$" validation-mex="^.*$" validation-mhl="^.*$" validation-mli="^.*$" validation-mdv="^.*$" validation-mys="^.*$"
validation-mwi="^.*$" validation-mac="^.*$" validation-lbr="^.*$" validation-lso="^.*$" validation-lao="^.*$" validation-kor="^.*$" validation-kir="^.*$" validation-ken="^.*$" validation-jey="^.*$" validation-jpn="^.*$"
validation-jam="^.*$" validation-imn="^.*$" validation-idn="^.*$" validation-ind="^.*$" validation-hkg="^.*$" validation-hnd="^.*$" validation-vat="^.*$" validation-hmd="^.*$" validation-hti="^.*$" validation-guy="^.*$"
validation-gnb="^.*$" validation-gin="^.*$" validation-ggy="^.*$" validation-gtm="^.*$" validation-gum="^.*$" validation-grd="^.*$" validation-grl="^.*$" validation-gha="^.*$" validation-gmb="^.*$" validation-gab="^.*$"
validation-atf="^.*$" validation-pyf="^.*$" validation-fji="^.*$" validation-fro="^.*$" validation-flk="^.*$" validation-eth="^.*$" validation-gnq="^.*$" validation-slv="^.*$" validation-egy="^.*$" validation-ecu="^.*$"
validation-dom="^.*$" validation-dma="^.*$" validation-dji="^.*$" validation-dnk="^.*$" validation-civ="^.*$" validation-cri="^.*$" validation-cok="^.*$" validation-cod="^.*$" validation-cog="^.*$" validation-com="^.*$"
validation-col="^.*$" validation-cck="^.*$" validation-cxr="^.*$" validation-chn="^.*$" validation-chl="^.*$" validation-tcd="^.*$" validation-caf="^.*$" validation-cym="^.*$" validation-cpv="^.*$" validation-can="^.*$"
validation-cmr="^.*$" validation-khm="^.*$" validation-bdi="^.*$" validation-bfa="^.*$" validation-brn="^.*$" validation-bra="^.*$" validation-bvt="^.*$" validation-bwa="^.*$" validation-bol="^.*$" validation-btn="^.*$"
validation-bmu="^.*$" validation-ben="^.*$" validation-blz="^.*$" validation-brb="^.*$" validation-bgd="^.*$" validation-bhs="^.*$" validation-aus="^.*$" validation-abw="^.*$" validation-arm="^.*$" validation-arg="^.*$"
validation-atg="^.*$" validation-ata="^.*$" validation-aia="^.*$" validation-ago="^.*$" validation-asm="^.*$" class="{ required: true,messages:{required:'Please enter your Account Number'}}" required="true" nocreditcard="true"
style="display: none;"> <span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback" style="display: none;"><label for="bankcode" class="control-label col-xs-2">Bank code</label>
<div class="input-group col-xs-8"><input type="text" name="bankcode" id="bankcode" data-countries="VIR,USA,GBR,PRI,MNP,JEY,IMN,IND,GUM,CAN,AUS,ASM," validation-vir="^.*$" validation-usa="^.*$" validation-gbr="^.*$"
validation-pri="^.*$" validation-mnp="^.*$" validation-jey="^.*$" validation-imn="^.*$" validation-ind="^.*$" validation-gum="^.*$" validation-can="^.*$" validation-aus="^.*$" validation-asm="^.*$"
class="{ required: true,messages:{required:'jscheckbankCode'}}" required="true" nocreditcard="true" style="display: none;"> <span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="swiftbsb" class="control-label col-xs-2">SWIFT / BSB</label>
<div class="input-group col-xs-8"><input type="text" name="swiftbsb" id="swiftbsb"
data-countries="CUW,ZWE,ZMB,YEM,ESH,WLF,VGB,VNM,VEN,VUT,UZB,URY,ARE,UKR,UGA,TUV,TCA,TKM,TUR,TUN,TTO,TON,TKL,TGO,TLS,THA,TZA,TJK,TWN,CHE,SWE,SWZ,SJM,SUR,LKA,ESP,SGS,ZAF,SOM,SLB,SVN,SVK,SGP,SLE,SYC,SRB,SEN,SAU,STP,SMR,WSM,VCT,SPM,LCA,KNA,SHN,RWA,RUS,ROU,REU,QAT,PRT,POL,PCN,PHL,PER,PRY,PNG,PAN,PSE,PLW,PAK,OMN,NOR,NFK,NIU,NGA,NER,NIC,NZL,NCL,ANT,NLD,NPL,NAM,MMR,MOZ,MAR,MSR,MNE,MNG,MCO,MDA,FSM,MEX,MYT,MUS,MRT,MTQ,MHL,MLT,MLI,MDV,MYS,MWI,MDG,MKD,MAC,LUX,LTU,LIE,LBR,LSO,LBN,LVA,LAO,KWT,KOR,KIR,KEN,KAZ,JOR,JPN,JAM,ITA,ISR,IRL,IDN,IND,ISL,HUN,HKG,HND,VAT,HMD,HTI,GUY,GNB,GIN,GGY,GTM,GLP,GRD,GRL,GRC,GIB,GHA,DEU,GEO,GMB,GAB,ATF,PYF,GUF,FRA,FIN,FJI,FRO,FLK,ETH,EST,GNQ,SLV,EGY,ECU,DOM,DMA,DJI,CZE,CYP,HRV,CIV,CRI,COK,COD,COG,COM,COL,CCK,CXR,CHN,CHL,TCD,CAF,CYM,CPV,CAN,CMR,KHM,BDI,BFA,BGR,BRN,BRA,BVT,BWA,BIH,BOL,BTN,BMU,BEN,BLZ,BEL,BLR,BRB,BHR,BHS,AZE,AUT,AUS,ABW,ARM,ARG,ATG,ATA,AIA,AGO,AND,DZA,ALB,ALA,"
validation-cuw="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-zwe="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-zmb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-yem="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-esh="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-wlf="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-vgb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-vnm="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-ven="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-vut="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-uzb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-ury="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-are="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-ukr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-uga="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tuv="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-tca="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tkm="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tur="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tun="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-tto="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-ton="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tkl="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tgo="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-tls="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tha="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tza="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tjk="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-twn="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-che="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-swe="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-swz="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-sjm="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-sur="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-lka="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-esp="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-sgs="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-zaf="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-som="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-slb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-svn="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-svk="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-sgp="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-sle="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-syc="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-srb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-sen="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-sau="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-stp="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-smr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-wsm="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-vct="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
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validation-grc="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-gib="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-gha="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-deu="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
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validation-cri="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cok="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cod="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cog="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-com="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-col="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cck="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cxr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-chn="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-chl="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-tcd="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-caf="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-cym="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cpv="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-can="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-cmr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-khm="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bdi="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bfa="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bgr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-brn="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bra="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bvt="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bwa="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-bih="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bol="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-btn="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bmu="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-ben="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-blz="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bel="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-blr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-brb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bhr="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-bhs="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-aze="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-aut="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-aus="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-abw="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-arm="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-arg="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-atg="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-ata="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-aia="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-ago="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-and="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-dza="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" validation-alb="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$"
validation-ala="^[A-Z]{6}[A-Z0-9]{2}([A-Z0-9]{3})?$" class="{ required: true,messages:{required:'Please enter your Swift or BSB Number'}}" required="true" nocreditcard="true"> <span
class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="iban" class="control-label col-xs-2">IBAN</label>
<div class="input-group col-xs-8"><input type="text" name="iban" id="iban"
data-countries="ARE,TUR,TUN,CHE,SWE,ESP,SVN,SVK,SRB,SAU,SMR,SPM,ROU,REU,QAT,PRT,POL,PSE,PAK,NOR,NLD,MNE,MCO,MDA,MYT,MUS,MRT,MTQ,MLT,MDG,MKD,LUX,LTU,LIE,LBN,LVA,KWT,KAZ,JOR,ITA,ISR,IRL,ISL,HUN,GLP,GRC,GIB,DEU,GEO,GUF,FRA,FIN,EST,CZE,CYP,HRV,BGR,BIH,BEL,BLR,BHR,AZE,AUT,AND,DZA,ALB,ALA,"
validation-are="^(AE\d{21})$" validation-tur="^(TR\d{24})$" validation-tun="^(TN\d{22})$" validation-che="^(CH\d{19})$" validation-swe="^(SE\d{22})$" validation-esp="^(ES\d{22})$" validation-svn="^(SI\d{17})$"
validation-svk="^(SK\d{22})$" validation-srb="^.*$" validation-sau="^(SA\d{22})$" validation-smr="^(SM\d{2}[A-Z]{1}\d{22})$" validation-spm="^.*$" validation-rou="^(RO\d{2}[A-Z]{4}\d{16})$" validation-reu="^.*$"
validation-qat="^(QA\d{2}[A-Z]{4}\d{21})$" validation-prt="^(PT\d{23})$" validation-pol="^(PL\d{26})$" validation-pse="^(PS\d{2}[A-Z]{4}\d{21})$" validation-pak="^(PK\d{2}[A-Z]{4}\d{16})$" validation-nor="^(NO\d{13})$"
validation-nld="^(NL\d{2}[A-Z]{4}\d{10})$" validation-mne="^(ME\d{20})$" validation-mco="^(MC\d{25})$" validation-mda="^(MD\d{2}[A-Z]{2}\d{18})$" validation-myt="^.*$" validation-mus="^(MU\d{2}[A-Z]{4}\d{19}[A-Z]{3})$"
validation-mrt="^(MR\d{25})$" validation-mtq="^.*$" validation-mlt="^(MT\d{2}[A-Z]{4}\d{23})$" validation-mdg="^.*$" validation-mkd="^(MK\d{17})$" validation-lux="^(LU\d{18})$" validation-ltu="^(LT\d{18})$"
validation-lie="^(LI\d{19})$" validation-lbn="^(LB\d{26})$" validation-lva="^(LV\d{2}[A-Z]{4}\d{13})$" validation-kwt="^(KW\d{2}[A-Z]{4}\d{22})$" validation-kaz="^(KZ\d{18})$" validation-jor="^(JO\d{2}[A-Z]{4}\d{22})$"
validation-ita="^(IT\d{2}[A-Z]{1}\d{22})$" validation-isr="^(IL\d{21})$" validation-irl="^(IE\d{2}[A-Z]{4}\d{14})$" validation-isl="^(IS\d{24})$" validation-hun="^(HU\d{26})$" validation-glp="^.*$" validation-grc="^(GR\d{25})$"
validation-gib="^(GI\d{2}[A-Z]{4}\d{15})$" validation-deu="^(DE\d{20})$" validation-geo="^(GE\d{2}[A-Z]{2}\d{16})$" validation-guf="^.*$" validation-fra="^(FR\d{25})$" validation-fin="^(FI\d{16})$" validation-est="^(EE\d{18})$"
validation-cze="^(CZ\d{22})$" validation-cyp="^(CY\d{26})$" validation-hrv="^(HR\d{19})$" validation-bgr="^(BG\d{2}[A-Z]{4}\d{14})$" validation-bih="^(BA\d{18})$" validation-bel="^(BE\d{14})$"
validation-blr="^(BY\d{2}[A-Z]{4}\d{20})$" validation-bhr="^(BH\d{2}[A-Z]{4}\d{14})$" validation-aze="^(AZ\d{2}[A-Z]{4}\d{20})$" validation-aut="^(AT\d{18})$" validation-and="^(AD\d{26})$" validation-dza="^.*$"
validation-alb="^(AL\d{26})$" validation-ala="^.*$" class="{ required: true,messages:{required:'jscheckIban'}}" required="true" nocreditcard="true"> <span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
</div>
<div class="form-group">
<div class="col-xs-10">Bank additional information</div>
</div>
<div class="form-group has-feedback"><label for="bankname" class="control-label col-xs-2">Bank Name</label>
<div class="input-group col-xs-8"><input type="text" name="bankname" id="bankname" class="{ required: false } " nocreditcard="true"> </div>
</div>
<div class="form-group has-feedback"><label for="bankaddress1" class="control-label col-xs-2">Address 1</label>
<div class="input-group col-xs-8"><input type="text" name="bankaddress1" id="bankaddress1" class="{ required: false } " nocreditcard="true"> </div>
</div>
<div class="form-group has-feedback"><label for="bankaddress2" class="control-label col-xs-2">City</label>
<div class="input-group col-xs-8"><input type="text" name="bankaddress2" id="bankaddress2" class="{ required: false } " nocreditcard="true"> </div>
</div>
<div class="form-group has-feedback"><label for="bankcity" class="control-label col-xs-2">City</label>
<div class="input-group col-xs-8"><input type="text" name="bankcity" id="bankcity" class="{ required: false } " nocreditcard="true"> </div>
</div>
<div class="form-group has-feedback"><label for="bankstate" class="control-label col-xs-2">State</label>
<div class="input-group col-xs-8"><input type="text" name="bankstate" id="bankstate" class="{ required: false } " nocreditcard="true"> </div>
</div>
<div class="form-group has-feedback"><label for="bankcountry" class="control-label col-xs-2">Country</label>
<div class="input-group col-xs-8"><select name="bankcountry" id="bankcountry">
<option value="ÅLAND ISLANDS" isocountrycode="ALA">ÅLAND ISLANDS</option>
<option value="AFGHANISTAN" isocountrycode="AFG">AFGHANISTAN</option>
<option value="ALBANIA" isocountrycode="ALB">ALBANIA</option>
<option value="ALGERIA" isocountrycode="DZA">ALGERIA</option>
<option value="AMERICAN SAMOA" isocountrycode="ASM">AMERICAN SAMOA</option>
<option value="ANDORRA" isocountrycode="AND">ANDORRA</option>
<option value="ANGOLA" isocountrycode="AGO">ANGOLA</option>
<option value="ANGUILLA" isocountrycode="AIA">ANGUILLA</option>
<option value="ANTARCTICA" isocountrycode="ATA">ANTARCTICA</option>
<option value="ANTIGUA AND BARBUDA" isocountrycode="ATG">ANTIGUA AND BARBUDA</option>
<option value="ARGENTINA" isocountrycode="ARG">ARGENTINA</option>
<option value="ARMENIA" isocountrycode="ARM">ARMENIA</option>
<option value="ARUBA" isocountrycode="ABW">ARUBA</option>
<option value="AUSTRALIA" isocountrycode="AUS">AUSTRALIA</option>
<option value="AUSTRIA" isocountrycode="AUT">AUSTRIA</option>
<option value="AZERBAIJAN" isocountrycode="AZE">AZERBAIJAN</option>
<option value="BAHAMAS" isocountrycode="BHS">BAHAMAS</option>
<option value="BAHRAIN" isocountrycode="BHR">BAHRAIN</option>
<option value="BANGLADESH" isocountrycode="BGD">BANGLADESH</option>
<option value="BARBADOS" isocountrycode="BRB">BARBADOS</option>
<option value="BELARUS" isocountrycode="BLR">BELARUS</option>
<option value="BELGIUM" isocountrycode="BEL">BELGIUM</option>
<option value="BELIZE" isocountrycode="BLZ">BELIZE</option>
<option value="BENIN" isocountrycode="BEN">BENIN</option>
<option value="BERMUDA" isocountrycode="BMU">BERMUDA</option>
<option value="BHUTAN" isocountrycode="BTN">BHUTAN</option>
<option value="BOLIVIA (PLURINATIONAL STATE OF)" isocountrycode="BOL">BOLIVIA (PLURINATIONAL STATE OF)</option>
<option value="BONAIRE. SINT EUSTATIUS AND SABA" isocountrycode="BES">BONAIRE. SINT EUSTATIUS AND SABA</option>
<option value="BOSNIA AND HERZEGOVINA" isocountrycode="BIH">BOSNIA AND HERZEGOVINA</option>
<option value="BOTSWANA" isocountrycode="BWA">BOTSWANA</option>
<option value="BOUVET ISLAND" isocountrycode="BVT">BOUVET ISLAND</option>
<option value="BRAZIL" isocountrycode="BRA">BRAZIL</option>
<option value="BRITISH INDIAN OCEAN TERRITORY" isocountrycode="IOT">BRITISH INDIAN OCEAN TERRITORY</option>
<option value="BRUNEI DARUSSALAM" isocountrycode="BRN">BRUNEI DARUSSALAM</option>
<option value="BULGARIA" isocountrycode="BGR">BULGARIA</option>
<option value="BURKINA FASO" isocountrycode="BFA">BURKINA FASO</option>
<option value="BURUNDI" isocountrycode="BDI">BURUNDI</option>
<option value="CôTE D'IVOIRE" isocountrycode="CIV">CôTE D'IVOIRE</option>
<option value="CABO VERDE" isocountrycode="CPV">CABO VERDE</option>
<option value="CAMBODIA" isocountrycode="KHM">CAMBODIA</option>
<option value="CAMEROON" isocountrycode="CMR">CAMEROON</option>
<option value="CANADA" isocountrycode="CAN">CANADA</option>
<option value="CAYMAN ISLANDS" isocountrycode="CYM">CAYMAN ISLANDS</option>
<option value="CENTRAL AFRICAN REPUBLIC" isocountrycode="CAF">CENTRAL AFRICAN REPUBLIC</option>
<option value="CHAD" isocountrycode="TCD">CHAD</option>
<option value="CHILE" isocountrycode="CHL">CHILE</option>
<option value="CHINA" isocountrycode="CHN">CHINA</option>
<option value="CHRISTMAS ISLAND" isocountrycode="CXR">CHRISTMAS ISLAND</option>
<option value="COCOS (KEELING) ISLANDS" isocountrycode="CCK">COCOS (KEELING) ISLANDS</option>
<option value="COLOMBIA" isocountrycode="COL">COLOMBIA</option>
<option value="COMOROS" isocountrycode="COM">COMOROS</option>
<option value="CONGO" isocountrycode="COG">CONGO</option>
<option value="CONGO (DEMOCRATIC REPUBLIC OF THE)" isocountrycode="COD">CONGO (DEMOCRATIC REPUBLIC OF THE)</option>
<option value="COOK ISLANDS" isocountrycode="COK">COOK ISLANDS</option>
<option value="COSTA RICA" isocountrycode="CRI">COSTA RICA</option>
<option value="CROATIA" isocountrycode="HRV">CROATIA</option>
<option value="CUBA" isocountrycode="CUB">CUBA</option>
<option value="CURAÇAO" isocountrycode="CUW">CURAÇAO</option>
<option value="CYPRUS" isocountrycode="CYP">CYPRUS</option>
<option value="CZECHIA" isocountrycode="CZE">CZECHIA</option>
<option value="DENMARK" isocountrycode="DNK">DENMARK</option>
<option value="DJIBOUTI" isocountrycode="DJI">DJIBOUTI</option>
<option value="DOMINICA" isocountrycode="DMA">DOMINICA</option>
<option value="DOMINICAN REPUBLIC" isocountrycode="DOM">DOMINICAN REPUBLIC</option>
<option value="ECUADOR" isocountrycode="ECU">ECUADOR</option>
<option value="EGYPT" isocountrycode="EGY">EGYPT</option>
<option value="EL SALVADOR" isocountrycode="SLV">EL SALVADOR</option>
<option value="EQUATORIAL GUINEA" isocountrycode="GNQ">EQUATORIAL GUINEA</option>
<option value="ERITREA" isocountrycode="ERI">ERITREA</option>
<option value="ESTONIA" isocountrycode="EST">ESTONIA</option>
<option value="ETHIOPIA" isocountrycode="ETH">ETHIOPIA</option>
<option value="FALKLAND ISLANDS (MALVINAS)" isocountrycode="FLK">FALKLAND ISLANDS (MALVINAS)</option>
<option value="FAROE ISLANDS" isocountrycode="FRO">FAROE ISLANDS</option>
<option value="FIJI" isocountrycode="FJI">FIJI</option>
<option value="FINLAND" isocountrycode="FIN">FINLAND</option>
<option value="FRANCE" isocountrycode="FRA">FRANCE</option>
<option value="FRENCH GUIANA" isocountrycode="GUF">FRENCH GUIANA</option>
<option value="FRENCH POLYNESIA" isocountrycode="PYF">FRENCH POLYNESIA</option>
<option value="FRENCH SOUTHERN TERRITORIES" isocountrycode="ATF">FRENCH SOUTHERN TERRITORIES</option>
<option value="GABON" isocountrycode="GAB">GABON</option>
<option value="GAMBIA" isocountrycode="GMB">GAMBIA</option>
<option value="GEORGIA" isocountrycode="GEO">GEORGIA</option>
<option value="GERMANY" isocountrycode="DEU">GERMANY</option>
<option value="GHANA" isocountrycode="GHA">GHANA</option>
<option value="GIBRALTAR" isocountrycode="GIB">GIBRALTAR</option>
<option value="GREECE" isocountrycode="GRC">GREECE</option>
<option value="GREENLAND" isocountrycode="GRL">GREENLAND</option>
<option value="GRENADA" isocountrycode="GRD">GRENADA</option>
<option value="GUADELOUPE" isocountrycode="GLP">GUADELOUPE</option>
<option value="GUAM" isocountrycode="GUM">GUAM</option>
<option value="GUATEMALA" isocountrycode="GTM">GUATEMALA</option>
<option value="GUERNSEY" isocountrycode="GGY">GUERNSEY</option>
<option value="GUINEA" isocountrycode="GIN">GUINEA</option>
<option value="GUINEA-BISSAU" isocountrycode="GNB">GUINEA-BISSAU</option>
<option value="GUYANA" isocountrycode="GUY">GUYANA</option>
<option value="HAITI" isocountrycode="HTI">HAITI</option>
<option value="HEARD ISLAND AND MCDONALD ISLA" isocountrycode="HMD">HEARD ISLAND AND MCDONALD ISLA</option>
<option value="HOLY SEE" isocountrycode="VAT">HOLY SEE</option>
<option value="HONDURAS" isocountrycode="HND">HONDURAS</option>
<option value="HONG KONG" isocountrycode="HKG">HONG KONG</option>
<option value="HUNGARY" isocountrycode="HUN">HUNGARY</option>
<option value="ICELAND" isocountrycode="ISL">ICELAND</option>
<option value="INDIA" isocountrycode="IND">INDIA</option>
<option value="INDONESIA" isocountrycode="IDN">INDONESIA</option>
<option value="IRAN (ISLAMIC REPUBLIC OF)" isocountrycode="IRN">IRAN (ISLAMIC REPUBLIC OF)</option>
<option value="IRAQ" isocountrycode="IRQ">IRAQ</option>
<option value="IRELAND" isocountrycode="IRL">IRELAND</option>
<option value="ISLE OF MAN" isocountrycode="IMN">ISLE OF MAN</option>
<option value="ISRAEL" isocountrycode="ISR">ISRAEL</option>
<option value="ITALY" isocountrycode="ITA">ITALY</option>
<option value="JAMAICA" isocountrycode="JAM">JAMAICA</option>
<option value="JAPAN" isocountrycode="JPN">JAPAN</option>
<option value="JERSEY" isocountrycode="JEY">JERSEY</option>
<option value="JORDAN" isocountrycode="JOR">JORDAN</option>
<option value="KAZAKHSTAN" isocountrycode="KAZ">KAZAKHSTAN</option>
<option value="KENYA" isocountrycode="KEN">KENYA</option>
<option value="KIRIBATI" isocountrycode="KIR">KIRIBATI</option>
<option value="KOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF)" isocountrycode="PRK">KOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF)</option>
<option value="KOREA (REPUBLIC OF)" isocountrycode="KOR">KOREA (REPUBLIC OF)</option>
<option value="KUWAIT" isocountrycode="KWT">KUWAIT</option>
<option value="KYRGYZSTAN" isocountrycode="KGZ">KYRGYZSTAN</option>
<option value="LAO PEOPLE'S DEMOCRATIC REPUBLIC" isocountrycode="LAO">LAO PEOPLE'S DEMOCRATIC REPUBLIC</option>
<option value="LATVIA" isocountrycode="LVA">LATVIA</option>
<option value="LEBANON" isocountrycode="LBN">LEBANON</option>
<option value="LESOTHO" isocountrycode="LSO">LESOTHO</option>
<option value="LIBERIA" isocountrycode="LBR">LIBERIA</option>
<option value="LIBYA" isocountrycode="LBY">LIBYA</option>
<option value="LIECHTENSTEIN" isocountrycode="LIE">LIECHTENSTEIN</option>
<option value="LITHUANIA" isocountrycode="LTU">LITHUANIA</option>
<option value="LUXEMBOURG" isocountrycode="LUX">LUXEMBOURG</option>
<option value="MACAO" isocountrycode="MAC">MACAO</option>
<option value="MACEDONIA (THE FORMER YUGOSLAV REPUBLIC OF)" isocountrycode="MKD">MACEDONIA (THE FORMER YUGOSLAV REPUBLIC OF)</option>
<option value="MADAGASCAR" isocountrycode="MDG">MADAGASCAR</option>
<option value="MALAWI" isocountrycode="MWI">MALAWI</option>
<option value="MALAYSIA" isocountrycode="MYS">MALAYSIA</option>
<option value="MALDIVES" isocountrycode="MDV">MALDIVES</option>
<option value="MALI" isocountrycode="MLI">MALI</option>
<option value="MALTA" isocountrycode="MLT">MALTA</option>
<option value="MARSHALL ISLANDS" isocountrycode="MHL">MARSHALL ISLANDS</option>
<option value="MARTINIQUE" isocountrycode="MTQ">MARTINIQUE</option>
<option value="MAURITANIA" isocountrycode="MRT">MAURITANIA</option>
<option value="MAURITIUS" isocountrycode="MUS">MAURITIUS</option>
<option value="MAYOTTE" isocountrycode="MYT">MAYOTTE</option>
<option value="MEXICO" isocountrycode="MEX">MEXICO</option>
<option value="MICRONESIA (FEDERATED STATES OF)" isocountrycode="FSM">MICRONESIA (FEDERATED STATES OF)</option>
<option value="MOLDOVA (REPUBLIC OF)" isocountrycode="MDA">MOLDOVA (REPUBLIC OF)</option>
<option value="MONACO" isocountrycode="MCO">MONACO</option>
<option value="MONGOLIA" isocountrycode="MNG">MONGOLIA</option>
<option value="MONTENEGRO" isocountrycode="MNE">MONTENEGRO</option>
<option value="MONTSERRAT" isocountrycode="MSR">MONTSERRAT</option>
<option value="MOROCCO" isocountrycode="MAR">MOROCCO</option>
<option value="MOZAMBIQUE" isocountrycode="MOZ">MOZAMBIQUE</option>
<option value="MYANMAR" isocountrycode="MMR">MYANMAR</option>
<option value="NAMIBIA" isocountrycode="NAM">NAMIBIA</option>
<option value="NAURU" isocountrycode="NRU">NAURU</option>
<option value="NEPAL" isocountrycode="NPL">NEPAL</option>
<option value="NETHERLANDS" isocountrycode="NLD">NETHERLANDS</option>
<option value="NETHERLANDS ANTILLES" isocountrycode="ANT">NETHERLANDS ANTILLES</option>
<option value="NEW CALEDONIA" isocountrycode="NCL">NEW CALEDONIA</option>
<option value="NEW ZEALAND" isocountrycode="NZL">NEW ZEALAND</option>
<option value="NICARAGUA" isocountrycode="NIC">NICARAGUA</option>
<option value="NIGER" isocountrycode="NER">NIGER</option>
<option value="NIGERIA" isocountrycode="NGA">NIGERIA</option>
<option value="NIUE" isocountrycode="NIU">NIUE</option>
<option value="NORFOLK ISLAND" isocountrycode="NFK">NORFOLK ISLAND</option>
<option value="NORTHERN MARIANA ISLANDS" isocountrycode="MNP">NORTHERN MARIANA ISLANDS</option>
<option value="NORWAY" isocountrycode="NOR">NORWAY</option>
<option value="OMAN" isocountrycode="OMN">OMAN</option>
<option value="PAKISTAN" isocountrycode="PAK">PAKISTAN</option>
<option value="PALAU" isocountrycode="PLW">PALAU</option>
<option value="PALESTINE. STATE OF" isocountrycode="PSE">PALESTINE. STATE OF</option>
<option value="PANAMA" isocountrycode="PAN">PANAMA</option>
<option value="PAPUA NEW GUINEA" isocountrycode="PNG">PAPUA NEW GUINEA</option>
<option value="PARAGUAY" isocountrycode="PRY">PARAGUAY</option>
<option value="PERU" isocountrycode="PER">PERU</option>
<option value="PHILIPPINES" isocountrycode="PHL">PHILIPPINES</option>
<option value="PITCAIRN" isocountrycode="PCN">PITCAIRN</option>
<option value="POLAND" isocountrycode="POL">POLAND</option>
<option value="PORTUGAL" isocountrycode="PRT">PORTUGAL</option>
<option value="PUERTO RICO" isocountrycode="PRI">PUERTO RICO</option>
<option value="QATAR" isocountrycode="QAT">QATAR</option>
<option value="RÉUNION" isocountrycode="REU">RÉUNION</option>
<option value="ROMANIA" isocountrycode="ROU">ROMANIA</option>
<option value="RUSSIAN FEDERATION" isocountrycode="RUS">RUSSIAN FEDERATION</option>
<option value="RWANDA" isocountrycode="RWA">RWANDA</option>
<option value="SAINT BARTHÉLEMY" isocountrycode="BLM">SAINT BARTHÉLEMY</option>
<option value="SAINT HELENA. ASCENSION AND TRISTAN DA CUNHA" isocountrycode="SHN">SAINT HELENA. ASCENSION AND TRISTAN DA CUNHA</option>
<option value="SAINT KITTS AND NEVIS" isocountrycode="KNA">SAINT KITTS AND NEVIS</option>
<option value="SAINT LUCIA" isocountrycode="LCA">SAINT LUCIA</option>
<option value="SAINT MARTIN (FRENCH PART)" isocountrycode="MAF">SAINT MARTIN (FRENCH PART)</option>
<option value="SAINT PIERRE AND MIQUELON" isocountrycode="SPM">SAINT PIERRE AND MIQUELON</option>
<option value="SAINT VINCENT AND THE GRENADIN" isocountrycode="VCT">SAINT VINCENT AND THE GRENADIN</option>
<option value="SAMOA" isocountrycode="WSM">SAMOA</option>
<option value="SAN MARINO" isocountrycode="SMR">SAN MARINO</option>
<option value="SAO TOME AND PRINCIPE" isocountrycode="STP">SAO TOME AND PRINCIPE</option>
<option value="SAUDI ARABIA" isocountrycode="SAU">SAUDI ARABIA</option>
<option value="SENEGAL" isocountrycode="SEN">SENEGAL</option>
<option value="SERBIA" isocountrycode="SRB">SERBIA</option>
<option value="SEYCHELLES" isocountrycode="SYC">SEYCHELLES</option>
<option value="SIERRA LEONE" isocountrycode="SLE">SIERRA LEONE</option>
<option value="SINGAPORE" isocountrycode="SGP">SINGAPORE</option>
<option value="SINT MAARTEN (DUTCH PART)" isocountrycode="SXM">SINT MAARTEN (DUTCH PART)</option>
<option value="SLOVAKIA" isocountrycode="SVK">SLOVAKIA</option>
<option value="SLOVENIA" isocountrycode="SVN">SLOVENIA</option>
<option value="SOLOMON ISLANDS" isocountrycode="SLB">SOLOMON ISLANDS</option>
<option value="SOMALIA" isocountrycode="SOM">SOMALIA</option>
<option value="SOUTH AFRICA" isocountrycode="ZAF">SOUTH AFRICA</option>
<option value="SOUTH GEORGIA AND THE SOUTH SA" isocountrycode="SGS">SOUTH GEORGIA AND THE SOUTH SA</option>
<option value="SOUTH SUDAN" isocountrycode="SSD">SOUTH SUDAN</option>
<option value="SPAIN" isocountrycode="ESP">SPAIN</option>
<option value="SRI LANKA" isocountrycode="LKA">SRI LANKA</option>
<option value="SUDAN" isocountrycode="SDN">SUDAN</option>
<option value="SURINAME" isocountrycode="SUR">SURINAME</option>
<option value="SVALBARD AND JAN MAYEN" isocountrycode="SJM">SVALBARD AND JAN MAYEN</option>
<option value="SWAZILAND" isocountrycode="SWZ">SWAZILAND</option>
<option value="SWEDEN" isocountrycode="SWE">SWEDEN</option>
<option value="SWITZERLAND" isocountrycode="CHE">SWITZERLAND</option>
<option value="SYRIAN ARAB REPUBLIC" isocountrycode="SYR">SYRIAN ARAB REPUBLIC</option>
<option value="TAIWAN" isocountrycode="TWN">TAIWAN</option>
<option value="TAJIKISTAN" isocountrycode="TJK">TAJIKISTAN</option>
<option value="TANZANIA, UNITED REPUBLIC OF" isocountrycode="TZA">TANZANIA, UNITED REPUBLIC OF</option>
<option value="THAILAND" isocountrycode="THA">THAILAND</option>
<option value="TIMOR-LESTE" isocountrycode="TLS">TIMOR-LESTE</option>
<option value="TOGO" isocountrycode="TGO">TOGO</option>
<option value="TOKELAU" isocountrycode="TKL">TOKELAU</option>
<option value="TONGA" isocountrycode="TON">TONGA</option>
<option value="TRINIDAD AND TOBAGO" isocountrycode="TTO">TRINIDAD AND TOBAGO</option>
<option value="TUNISIA" isocountrycode="TUN">TUNISIA</option>
<option value="TURKEY" isocountrycode="TUR">TURKEY</option>
<option value="TURKMENISTAN" isocountrycode="TKM">TURKMENISTAN</option>
<option value="TURKS AND CAICOS ISLANDS" isocountrycode="TCA">TURKS AND CAICOS ISLANDS</option>
<option value="TUVALU" isocountrycode="TUV">TUVALU</option>
<option value="UGANDA" isocountrycode="UGA">UGANDA</option>
<option value="UKRAINE" isocountrycode="UKR">UKRAINE</option>
<option value="UNITED ARAB EMIRATES" isocountrycode="ARE">UNITED ARAB EMIRATES</option>
<option value="UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND" isocountrycode="GBR">UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND</option>
<option value="UNITED STATES MINOR OUTLYING I" isocountrycode="UMI">UNITED STATES MINOR OUTLYING I</option>
<option value="UNITED STATES OF AMERICA" isocountrycode="USA">UNITED STATES OF AMERICA</option>
<option value="URUGUAY" isocountrycode="URY">URUGUAY</option>
<option value="UZBEKISTAN" isocountrycode="UZB">UZBEKISTAN</option>
<option value="VANUATU" isocountrycode="VUT">VANUATU</option>
<option value="VENEZUELA (BOLIVARIAN REPUBLIC OF)" isocountrycode="VEN">VENEZUELA (BOLIVARIAN REPUBLIC OF)</option>
<option value="VIET NAM" isocountrycode="VNM">VIET NAM</option>
<option value="VIRGIN ISLANDS (BRITISH)" isocountrycode="VGB">VIRGIN ISLANDS (BRITISH)</option>
<option value="VIRGIN ISLANDS (U.S.)" isocountrycode="VIR">VIRGIN ISLANDS (U.S.)</option>
<option value="WALLIS AND FUTUNA" isocountrycode="WLF">WALLIS AND FUTUNA</option>
<option value="WESTERN SAHARA" isocountrycode="ESH">WESTERN SAHARA</option>
<option value="YEMEN" isocountrycode="YEM">YEMEN</option>
<option value="YUGOSLAVIA" isocountrycode="">YUGOSLAVIA</option>
<option value="ZAMBIA" isocountrycode="ZMB">ZAMBIA</option>
<option value="ZIMBABWE" isocountrycode="ZWE">ZIMBABWE</option>
</select> </div>
</div>
<div class="form-group has-feedback"><label for="bankzip" class="control-label col-xs-2">zipcode</label>
<div class="input-group col-xs-8"><input type="text" name="bankzip" id="bankzip" class="{ required: false } " nocreditcard="true"> </div>
</div>
<div class="form-group">
<div class="col-xs-10">bankinfo</div>
</div>
<div class="form-group has-feedback"><label for="extrainfo" class="control-label col-xs-2"></label>
<div class="input-group col-xs-8"><textarea name="extrainfo" id="extrainfo" cols="50" rows="4"> </textarea> </div>
</div>
</div>
</div>
<div class="row">
<span class="next btn btn-info pull-left" data-current-block="2" data-next-block="1"><i class="fa fa-angle-double-left fa-2x"></i></span>
<span class="next btn btn-info pull-right" data-current-block="2" data-next-block="3"><i class="fa fa-angle-double-right fa-2x"></i></span>
</div>
</div>
<!-- panel last-->
<div class="wizardpanel block3 hidden" id="block3">
<div class="row">
<div class="form-group has-feedback"><label for="siteurl" class="control-label col-xs-2">Website URL </label>
<div class="input-group col-xs-10"><input name="siteurl" id="siteurl" type="text" value="http://" url="true" maxlength="140" size="40" minlength=""><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="category" class="control-label col-xs-2">Category </label>
<div class="input-group col-xs-10"><select name="category" id="category"="true"="">
<option value=""></option>
<option value="Arts">Arts</option>
<option value="Business">Business</option>
<option value="Computers">Computers</option>
<option value="Games">Games</option>
<option value="Gaming">Gaming</option>
<option value="Health">Health</option>
<option value="News">News</option>
<option value="Recreation">Recreation</option>
<option value="Reference">Reference</option>
<option value="Regional">Regional</option>
<option value="Science">Science</option>
<option value="Shopping">Shopping</option>
<option value="Society">Society</option>
<option value="Sports">Sports</option>
<option value="test">test</option>
<option value="World">World</option>
</select><span class="input-group-addon"><i class="fa "></i></span></div>
</div>
<div class="form-group has-feedback"><label for="targetmarket" class="control-label col-xs-2">Target Market Detail </label>
<div class="input-group col-xs-10"><select name="targetmarket" id="targetmarket" required="true" class="{required:true,messages:{required:'Select an option that best describes your Primary Target Market.'}}"="true"="">
<option value=""></option> @status=1,@langid=1<option value="Brazil">Brazil</option>
<option value="Other">Other</option>
</select><span class="input-group-addon"><i class="fa fa fa-asterisk "></i></span></div>
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* Terms and Conditions * Contact us * * * * * Login * Join Now REGISTRATION FORM * 1PERSONAL * 2PAYMENTS * 3ADDITIONAL PERSONAL DETAILS Username Password Re-Type Password Please enter the text as it appears in the image above. Select a security question Your first pet's name OR enter your own security question Security Question Answer CONTACT DETAILS Email Address Re-enter Email First Name Last Name Company Name Contact Phone Cell Phone IM name Skype Name Address 1 City State Zip Country ÅLAND ISLANDSAFGHANISTANALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUA AND BARBUDAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIA (PLURINATIONAL STATE OF)BONAIRE. SINT EUSTATIUS AND SABABOSNIA AND HERZEGOVINABOTSWANABOUVET ISLANDBRAZILBRITISH INDIAN OCEAN TERRITORYBRUNEI DARUSSALAMBULGARIABURKINA FASOBURUNDICôTE D'IVOIRECABO VERDECAMBODIACAMEROONCANADACAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHILECHINACHRISTMAS ISLANDCOCOS (KEELING) ISLANDSCOLOMBIACOMOROSCONGOCONGO (DEMOCRATIC REPUBLIC OF THE)COOK ISLANDSCOSTA RICACROATIACUBACURAÇAOCYPRUSCZECHIADENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDS (MALVINAS)FAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAFRENCH SOUTHERN TERRITORIESGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUATEMALAGUERNSEYGUINEAGUINEA-BISSAUGUYANAHAITIHEARD ISLAND AND MCDONALD ISLAHOLY SEEHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRAN (ISLAMIC REPUBLIC OF)IRAQIRELANDISLE OF MANISRAELITALYJAMAICAJAPANJERSEYJORDANKAZAKHSTANKENYAKIRIBATIKOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF)KOREA (REPUBLIC OF)KUWAITKYRGYZSTANLAO PEOPLE'S DEMOCRATIC REPUBLICLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIA (THE FORMER YUGOSLAV REPUBLIC OF)MADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIA (FEDERATED STATES OF)MOLDOVA (REPUBLIC OF)MONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MARIANA ISLANDSNORWAYOMANPAKISTANPALAUPALESTINE. STATE OFPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPITCAIRNPOLANDPORTUGALPUERTO RICOQATARRÉUNIONROMANIARUSSIAN FEDERATIONRWANDASAINT BARTHÉLEMYSAINT HELENA. ASCENSION AND TRISTAN DA CUNHASAINT KITTS AND NEVISSAINT LUCIASAINT MARTIN (FRENCH PART)SAINT PIERRE AND MIQUELONSAINT VINCENT AND THE GRENADINSAMOASAN MARINOSAO TOME AND PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESINT MAARTEN (DUTCH PART)SLOVAKIASLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH GEORGIA AND THE SOUTH SASOUTH SUDANSPAINSRI LANKASUDANSURINAMESVALBARD AND JAN MAYENSWAZILANDSWEDENSWITZERLANDSYRIAN ARAB REPUBLICTAIWANTAJIKISTANTANZANIA, UNITED REPUBLIC OFTHAILANDTIMOR-LESTETOGOTOKELAUTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS AND CAICOS ISLANDSTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELANDUNITED STATES MINOR OUTLYING IUNITED STATES OF AMERICAURUGUAYUZBEKISTANVANUATUVENEZUELA (BOLIVARIAN REPUBLIC OF)VIET NAMVIRGIN ISLANDS (BRITISH)VIRGIN ISLANDS (U.S.)WALLIS AND FUTUNAWESTERN SAHARAYEMENYUGOSLAVIAZAMBIAZIMBABWE Payment Method BANK [EUR]NETELLER [EUR]Skrill [EUR] BANK Account holder information First Name Last Name Email Address Birthdate (YYYY-MM-DD) Bank account information Account No Bank code SWIFT / BSB IBAN Bank additional information Bank Name Address 1 City City State Country ÅLAND ISLANDSAFGHANISTANALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUA AND BARBUDAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIA (PLURINATIONAL STATE OF)BONAIRE. SINT EUSTATIUS AND SABABOSNIA AND HERZEGOVINABOTSWANABOUVET ISLANDBRAZILBRITISH INDIAN OCEAN TERRITORYBRUNEI DARUSSALAMBULGARIABURKINA FASOBURUNDICôTE D'IVOIRECABO VERDECAMBODIACAMEROONCANADACAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHILECHINACHRISTMAS ISLANDCOCOS (KEELING) ISLANDSCOLOMBIACOMOROSCONGOCONGO (DEMOCRATIC REPUBLIC OF THE)COOK ISLANDSCOSTA RICACROATIACUBACURAÇAOCYPRUSCZECHIADENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDS (MALVINAS)FAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAFRENCH SOUTHERN TERRITORIESGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUATEMALAGUERNSEYGUINEAGUINEA-BISSAUGUYANAHAITIHEARD ISLAND AND MCDONALD ISLAHOLY SEEHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRAN (ISLAMIC REPUBLIC OF)IRAQIRELANDISLE OF MANISRAELITALYJAMAICAJAPANJERSEYJORDANKAZAKHSTANKENYAKIRIBATIKOREA (DEMOCRATIC PEOPLE'S REPUBLIC OF)KOREA (REPUBLIC OF)KUWAITKYRGYZSTANLAO PEOPLE'S DEMOCRATIC REPUBLICLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIA (THE FORMER YUGOSLAV REPUBLIC OF)MADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIA (FEDERATED STATES OF)MOLDOVA (REPUBLIC OF)MONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MARIANA ISLANDSNORWAYOMANPAKISTANPALAUPALESTINE. 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