






<div class="container text-justify margicso margi_mobi"  >




<script>
function FillBilling(f) {
  if(f.billingtoo.checked == true) {
    f.name.value = f.first_name.value;
    f.shaddress.value = f.address.value;
	f.shmobile.value = f.mobile.value;
	f.shtel.value = f.tel.value;
	f.shpin.value = f.pin.value;
	f.city.value = f.landmark.value;
  }
}
</script>




 <div class="col-md-3" ></div>
 
 
 
 
<form method="post" name="register_form">


 
 <div class="col-md-6 outer_register box_shadow" >

 
 <h4 > Registration</h2>
    
    <?php if($suc_msg){ ?>
    <div class="fontphp"><?php echo $suc_msg ; ?></div>
    <?php } ?>
    
    <?php if($error){ ?>
    <div class="err_msg"><?php echo $error ; ?></div>
    <?php } ?>


<div class="clr" style="width:100%;"></div>
   
		<label>Email ID *</label>
     
		<input name="email" id="email" required  class="input" size="25" maxlength="150" type="email"  value="<?php echo set_value('email','') ; ?>">
        <div id="email_div"></div>
     
    <?php if(form_error('email')){ ?><span class="fontphp2"><?php echo form_error('email') ; ?></span> <?php } ?>    
  	
    
   <input type="hidden" value="<?=$c_val?>" name="c_val"  />
   
   
		<label>Password *</label>
      
		<input name="password" id="ps2" class="input" size="25" maxlength="15" type="password" required  >
     
    <?php if(form_error('password')){ ?><script>window.document.register_form.password.focus();</script>
    <span class="fontphp2"><?php echo form_error('password') ; ?></span> <?php } ?>    
	
    
      
		<label>Confirm Password *</label>
       
		<input name="vpassword" class="input" size="25" maxlength="15" type="password" required  >
        <div id="gpass" style="color:#F00;"></div>
     
    <?php if(form_error('vpassword')){ ?><script>window.document.register_form.vpassword.focus();</script><tr><td colspan="2"><span class="fontphp2"><?php echo form_error('vpassword') ; ?></span><?php } ?>    

    
   
    
    
   <label>Your Name *</label>
    <input name="first_name" class="input" size="25" maxlength="50" type="text" value="<?php echo set_value('first_name','') ; ?>" required  >
    
    <?php if(form_error('first_name')){ ?><?php echo form_error('first_name') ; ?></span><?php } ?>
    
    
       	<label>Address *</label>
       
		<textarea name="address" cols="3" rows="2" class="input" required  ><?php echo set_value('address','') ; ?></textarea>
       
    <?php if(form_error('address')){ ?><?php echo form_error('address') ; ?></span> <?php } ?>   
    
    
   
   
           
   
   
   
   
		<label>Mobile number *</label>
		<input name="mobile" class="input" size="25" maxlength="12" required  type="text" value="<?php echo set_value('mobile','') ; ?>">
       
    <?php if(form_error('mobile')){ ?><script>window.document.register_form.mobile.focus();</script><span class="fontphp2"><?php echo form_error('mobile') ; ?></span><?php } ?>   
	
    
  
       	<label>Telephone </label>
		<input name="tel" class="input" size="25" maxlength="25" type="text" value="<?php echo set_value('tel','') ; ?>">
    
        
    <?php if(form_error('tel')){ ?><span class="fontphp2"><?php echo form_error('tel') ; ?></span> <?php } ?>    
    
     

    

    
    <label> Enter the result *</label>
     <div class="row">
     <div class="col-md-3" >
     <?php echo $capimage ; ?>

<?php if(form_error('captext')){ ?><script>window.document.register_form.captext.focus();</script><span class="fontphp2"><?php echo form_error('captext') ; ?></span> <?php } ?>

     
     </div>
     <div class="col-md-4" ><input type="text" name="captext" id="captext" required  class="input" size="10" maxlength="10" autocomplete="off"></div>
 
</div>


<p>&nbsp;</p>






<table width="100%" border="0" cellspacing="0" cellpadding="0">
  <tr valign="top">
    <td><input type="checkbox" name="terms" required /> </td>
    <td style="padding-left:10px;" > <span class="mobi_re_size ">Accept our <a href="<?php echo site_url( 'Terms') ; ?>">Terms and conditions</a> and
 <a href="<?php echo site_url( 'Privacy') ; ?>">Privacy Policy</a>. <br /> </span></td>
  </tr>
  <tr  valign="top" >
    <td><input type="checkbox" name="noti" value="1" /> </td>
    <td  style="padding-left:10px;"><span class="mobi_re_size ">Allow notifications</span></td>
  </tr>
</table>



   	
<p align="center" >
<br />
<input name="register" class="button-primary" style="float:none; width:200px;" value="Register" type="submit" onclick="return reg_val();">
</p>
   
    

    
    
    </div>
  
    
    

</form>


  </div>




