<?php

session_start();

if (isset($_SESSION['last_submit']) && time()-$_SESSION['last_submit'] < 1440)
    die('Your account registration has already been sent. If you made any errors while filling the form, please send us any email with your request for correction at info@boacorporationoffshore.com');
else
    $_SESSION['last_submit'] = time();

?>
	
<html>

<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>Application</title>
<LINK href="images/style.css" type=text/css rel=stylesheet>
<style type="text/css">
<!--
.style9 {color: #FFFFFF}
-->
</style>
<script>
        function validate(){

        var a = document.getElementById("password").value;
        var b = document.getElementById("confirm_password").value;
        if (a!=b) {
        alert("Passwords do no match");
        return false;
        }
    }
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</head>

<body topmargin="o" bottommargin="o">

<div align="center">
	<table border="0" width="800" cellspacing="0" cellpadding="0" id="table1" class="table">
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						<td bgcolor="#ffffff"><div align="center"><img src="../ib/images/logo.png" width="250" height="50" alt="" border="0"></div>
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			<td><hr color="#de0011"></td>
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			<div align="center">
				<table border="0" width="800" id="table4" height="127">
					<tr>
						<td height="39">
						<p align="left">&nbsp; </p></td>
					</tr>
					<tr>
          
						<td height="50"><p align="center"><font color="#de0011"><b><font color="#de0011"><marquee width="600" scrollamount="600" scrolldelay="500" loop="25">ALERT!!! DO NOT REFRESH this page! Fill this form carefully! You can only submit it once!</marquee></font></b>
						<br /><br />
						<?php echo $message; ?></font></p><form onSubmit="return validate();" action="createaccount.php" method="post" enctype="multipart/form-data" name="FormName" id="FormName">
                    <table width="448" border="0" align="center" cellpadding="0" cellspacing="2">
                      <tr bgcolor="#565E78">
                        <td height="25" colspan="2" bgcolor="#de0011"><strong><span class="style9">Personal Information </span> </strong></td>
                      </tr>
					  <tr>
                        <td>&nbsp;</td>
                      </tr>
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">First Name<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="firstname" name="firstname" type="text" size="25" value="" maxlength="200" required="yes" /></td>
                      </tr>


					  
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="last_name">Last Name<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="lastname" name="lastname" type="text" size="25" value="" maxlength="200" required="yes" /></td>
                      </tr>
                      
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="dob">Date of Birth<font color="#CC0000">*</font></label>
                        </div></td>
                        <td> <input type="date" id="dob" name="dob" required="yes" value="16-12-1960" /></td>
                      </tr>
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">Gender<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><select name="gender" required="yes" />
  <option selected value="Select">Select</option>
  <option value="Male">Male</option>
  <option value="Female">Female</option>
</select> </td>
                      </tr>
					  
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">Address<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="address" name="address" type="text" size="25" value="" maxlength="200" required="yes" /></td>
                      </tr>
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">City<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="city" name="city" type="text" size="10" value="" maxlength="50" required="yes" /></td>
                      </tr>
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">State<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="state" name="state" type="text" size="10" value="" maxlength="50" required="yes" /></td>
                      </tr>
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">Zip<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="zip" name="zip" type="text" size="6" value="" maxlength="10" required="yes" /></td>
                      </tr>
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="first_name">Country<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><select name="country" required="yes" />
<option value="">Select</option>
<option value="Afganistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antigua &amp; Barbuda">Antigua &amp; Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire">Bonaire</option>
<option value="Bosnia &amp; Herzegovina">Bosnia &amp; Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="American Indian Ocean Ter">American Indian Ocean Ter</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Canary Islands">Canary Islands</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Channel Islands">Channel Islands</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Island">Cocos Island</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote DIvoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaco">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Ter">French Southern Ter</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Great Britain">Great Britain</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Hawaii">Hawaii</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea North">Korea North</option>
<option value="Korea Sout">Korea South</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malaysia">Malaysia</option>
<option value="Malawi">Malawi</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Midway Islands">Midway Islands</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Nambia">Nambia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherland Antilles">Netherland Antilles</option>
<option value="Netherlands">Netherlands (Holland, Europe)</option>
<option value="Nevis">Nevis</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau Island">Palau Island</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Phillipines">Philippines</option>
<option value="Pitcairn Island">Pitcairn Island</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of Montenegro">Republic of Montenegro</option>
<option value="Republic of Serbia">Republic of Serbia</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="St Barthelemy">St Barthelemy</option>
<option value="St Eustatius">St Eustatius</option>
<option value="St Helena">St Helena</option>
<option value="St Kitts-Nevis">St Kitts-Nevis</option>
<option value="St Lucia">St Lucia</option>
<option value="St Maarten">St Maarten</option>
<option value="St Pierre &amp; Miquelon">St Pierre &amp; Miquelon</option>
<option value="St Vincent &amp; Grenadines">St Vincent &amp; Grenadines</option>
<option value="Saipan">Saipan</option>
<option value="Samoa">Samoa</option>
<option value="Samoa American">Samoa American</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome &amp; Principe">Sao Tome &amp; Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Tahiti">Tahiti</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad &amp; Tobago">Trinidad &amp; Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks &amp; Caicos Is">Turks &amp; Caicos Is</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Erimates">United Arab Emirates</option>
<option value="United States of America">United States of America</option>
<option value="United States of America">United States of America</option>
<option value="Uraguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City State">Vatican City State</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands (Brit)">Virgin Islands (Brit)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
<option value="Wake Island">Wake Island</option>
<option value="Wallis &amp; Futana Is">Wallis &amp; Futana Is</option>
<option value="Yemen">Yemen</option>
<option value="Zaire">Zaire</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select></td>
                      </tr>
					  
					  
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="phone">Mobile Phone<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="phone" name="phone" type="text" size="20" value="" maxlength="15" required="yes" /></td>
                      </tr>
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="email">E-mail<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="email" name="email" type="text" size="25" value="" maxlength="200" required="yes" /></td>
                      </tr>
					  
					  <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="email">Occupation<font color="#CC0000">*</font></label>
                        </div></td>
                        <td><input id="occupation" name="occupation" type="text" size="25" value="" maxlength="50" required="yes" /></td>
                      </tr>
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="password">Account&nbsp;Type<font color="#CC0000">*</font></label>
                        </div></td>
                        <td>
						     <select name="type" required="yes" />
  <option selected value="Select">Select</option>
  <option value="eBusiness">eBusiness</option>
  <option value="Current">Current</option>
  <option value="Savings">Savings</option>
  <option value="Business Plus">Business Plus</option>
</select></td>
                      </tr>
					  
					 <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="password">Currency<font color="#CC0000">*</font></label>
                        </div></td>
                        <td>
						     <select name="currency" required="yes" />
  <option selected value="Select">Select</option>
  <option value="&pound;">Pounds Sterling</option>
  <option value="&#x24;">US Dollars</option>
  <option value="&euro;">Euro</option>
  <option value="&yen;">Yen</option>
  <option value="&#8377;">Indian Rupee</option>
  <option value="&#8381;">Russian Rubble</option>
  <option value="&#20803;">Chinese Yuan</option>
</select></td>
                      </tr>
                      
			<tr>
                        <td><div align="right">Passport/Photo<font color="#CC0000">*</font></div></td>
                        <td><input name="picture" type="file" id="picture" />
</td>
                      </tr>
<tr>

                    <td height="23" valign="top"><div align="right"></div></td>

                    <td valign="top">
<font color="#de0011">Your passport photograph must not be more than 2MB in size and must be saved in any of these image formats: .jpg, .gif, .tif, .png and .bmp.</font></td>
	  
                      <tr>
                        <td>&nbsp;</td>
                        <td>&nbsp;</td>
                      </tr>
					  <tr>
                        <td>&nbsp;</td>
                        <td>&nbsp;</td>
                      </tr>
                      <tr bgcolor="#565E78">
                        <td height="25" colspan="2" bgcolor="#de0011"><span class="style9"><strong>Next of Kin details </strong></span></td>
                      </tr>
					  <tr>
                        <td>&nbsp;</td>
                      </tr>
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="next_of_kin_name">Next&nbsp;of&nbsp;Kin&nbsp;Name</label>
                        </div></td>
                        <td><input id="next_of_kin_name" name="next_of_kin_name" type="text" size="25" value="" maxlength="200" /></td>
                      </tr>
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="next_of_kin_address">Next&nbsp;of&nbsp;Kin&nbsp;Address</label>
                        </div></td>
                        <td><textarea id="next_of_kin_address" name="next_of_kin_address" rows="4" cols="40"></textarea></td>
                      </tr>
                      <tr>
                        <td width = "150"><div align="right" class="style14">
                            <label for="next_of_kin_phone">Next&nbsp;of&nbsp;Kin&nbsp;Phone</label>
                        </div></td>
                        <td><input id="next_of_kin_phone" name="next_of_kin_phone" type="text" size="25" value="" maxlength="15" /></td>
                      </tr>
					  <tr>
                        <td>&nbsp;</td>
                      </tr>
                      <tr>
                        <td width="150"></td>
                        <td><input type="submit" name="submit" value="Submit Application" /></td>
                      </tr>
                    </table>
			      </form>
						<p align="center"><a href="../ib/index.php"><strong>Go to Home</strong></a>                        
				      <p align="center"></td>
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						<td class="footer">
					  <p align="center"><font color="#FFFFFF">Copyright &copy; Bank of America. All Rights Reserved</font></td>
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