<b>date() [<a href='function.date'>function.date</a>]: It is not safe to rely on the system's timezone settings. Please use the date.timezone setting, the TZ environment variable or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/New_York' for 'EST/-5.0/no DST' instead</b><br /><br /> <div id="main-content" class="mc-left">

<script language="javascript" type="text/javascript">


function  up_ship_state(){
document.getElementById('state_s').value  = document.getElementById('state').options[document.getElementById('state').selectedIndex].value;

}

function  up_ship_form(){


document.getElementById('firstname_s').value = document.getElementById('firstname').value;
document.getElementById('lastname_s').value = document.getElementById('lastname').value;
document.getElementById('address_s').value = document.getElementById('address').value;
document.getElementById('address_s_2').value = document.getElementById('address_2').value;
document.getElementById('city_s').value = document.getElementById('city').value;
document.getElementById('zip_s').value = document.getElementById('zip').value;
document.getElementById('state_s').options[document.getElementById('state_s').selectedIndex].value = document.getElementById('state').options[document.getElementById('state').selectedIndex].value;
document.getElementById('state_s').options[document.getElementById('state_s').selectedIndex].text = document.getElementById('state').options[document.getElementById('state').selectedIndex].text;
document.getElementById('state_s').value  = document.getElementById('state').options[document.getElementById('state').selectedIndex].value;


}

function validate_form(form){

var missing_field = 0;

var all_fields = new Array("checkerror","email","emailinvalid","firstname","lastname","address","city","state","zip","firstname_s","lastname_s","address_s","city_s","state_s","zip_s","ccNum","ccvv","cc_type","ccNumInvalid");	


	for (var i=0;i<all_fields.length;i++){		
	document.getElementById(all_fields[i]+'_error').style.display = 'none';
	
	}	

if(!document.getElementById('email').value ){
document.getElementById('email_error').style.display = 'block';
missing_field = 1;
}
else
{
var reg = /^([A-Za-z0-9_\-\.])+\@([A-Za-z0-9_\-\.])+\.([A-Za-z]{2,4})$/;

   var address = document.getElementById('email').value;
   if(reg.test(address) == false) {
	document.getElementById('emailinvalid_error').style.display = 'block';
	}
}

if(!document.getElementById('cc_type').value){
	document.getElementById('cc_type_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('phone').value){
	document.getElementById('phone_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('firstname').value){
	document.getElementById('firstname_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('lastname').value){
	document.getElementById('lastname_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('address').value){
	document.getElementById('address_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('city').value){
	document.getElementById('city_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('state').value){
	document.getElementById('state_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('zip').value){
	document.getElementById('zip_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('firstname_s').value){
	document.getElementById('firstname_s_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('lastname_s').value){
	document.getElementById('lastname_s_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('address_s').value){
	document.getElementById('address_s_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('city_s').value){
	document.getElementById('city_s_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('state_s').value){
	document.getElementById('state_s_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('zip_s').value){
	document.getElementById('zip_s_error').style.display = 'block';
missing_field = 1;
}


if(!document.getElementById('ccNum').value){
	document.getElementById('ccNum_error').style.display = 'block';
missing_field = 1;
}

if(!document.getElementById('ccvv').value){
	document.getElementById('ccvv_error').style.display = 'block';
missing_field = 1;
}

if(missing_field == "1"){
	document.getElementById('checkerror_error').style.display = 'block';

return false;
}

}
</script>

<form method="post" name="websignupfrm" action="[~7~]"  onSubmit="return validate_form(this);">
		<img src="assets/images/cart/billing-info.png" />
	<div id="yconfirm">
		<h4 style="margin-bottom: 3px">Contact Information</h4>
		<p style="font-size: 11px; line-hieght: 14px; font-style: italic">All fields required unless indicated by *</p>
            <ul>
				<li><div class="error" id='email_error' >Enter Email</div>
                    <div class="error" id='emailinvalid_error' >Invalid Email</div>
                <label>Your Email: </label> <input type="text" id="email" name="email" value="mtbinary@gmail.com"/></li>
                
                <li><div class="error" id='phone_error' >Enter Phone</div>
                <label>Your Phone Number:</label><input type="text" name="phone" id="phone"  value="949-842-4155" /></li>
            </ul>
	</div>
	
	<div class="separator-line"></div>
	
	 
    <div id="yconfirm">
		<h4>Billing Address</h4>
		
            
            <ul>
              <li><div class="error" id='firstname_error' >Enter First Name</div>
                <label>First Name:</label><input type="text"  id="firstname" name="firstname"  value="Mark"></li>
              
              <li><div class="error" id='lastname_error' >Enter Last Name</div>
				<label>Last Name:</label> <input type="text"  id="lastname" name="lastname"  value="Mark"></li>

				<li><div class="error" id='address_error' >Enter Address</div>
				<label>Address:</label><input type="text"  name="address" id="address"  value="10942 Lake Court Road"></li>
					
				<li><label>Address 2 *</label><input type="text"  name="address_2" id="address_2"  value=""></li>
					
				<li><div class="error" id='city_error' >Enter City</div>
				<label>City:</label><input type="text"  name="city" id="city"  value="North Tustin"></li>
				
				<li><div class="error" id='state_error' >Select State</div>
				<label>State:</label><select id="state" name="state" onChange='up_ship_state()' class="state">

                  <option value="CA">CA</option> 					    <option value="AL">AL</option>
                        <option value="AK">AK</option>
                        <option value="AZ">AZ</option>
                        <option value="AR">AR</option>
                        <option value="CA">CA</option>
                        <option value="CO">CO</option>
                        <option value="CT">CT</option>
                        <option value="DC">DC</option>
                        
                        <option value="DE">DE</option>
                        <option value="FL">FL</option>
                        <option value="GA">GA</option>
                        <option value="HI">HI</option>
                        <option value="ID">ID</option>
                        <option value="IL">IL</option>
                        <option value="IN">IN</option>
                        <option value="IA">IA</option>
                        <option value="KS">KS</option>
                        
                        <option value="KY">KY</option>
                        <option value="LA">LA</option>
                        <option value="ME">ME</option>
                        <option value="MD">MD</option>
                        <option value="MA">MA</option>
                        <option value="MI">MI</option>
                        <option value="MN">MN</option>
                        <option value="MS">MS</option>
                        <option value="MO">MO</option>
                        
                        <option value="MT">MT</option>
                        <option value="NE">NE</option>
                        <option value="NV">NV</option>
                        <option value="NH">NH</option>
                        <option value="NJ">NJ</option>
                        <option value="NM">NM</option>
                        <option value="NY">NY</option>
                        <option value="NC">NC</option>
                        <option value="ND">ND</option>
                        
                        <option value="OH">OH</option>
                        <option value="OK">OK</option>
                        <option value="OR">OR</option>
                        <option value="PA">PA</option>
                        <option value="RI">RI</option>
                        <option value="SC">SC</option>
                        <option value="SD">SD</option>
                        <option value="TN">TN</option>
                        <option value="TX">TX</option>
                        
                        <option value="UT">UT</option>
                        <option value="VT">VT</option>
                        <option value="VA">VA</option>
                        <option value="WA">WA</option>
                        <option value="WV">WV</option>
                        <option value="WI">WI</option>
                        <option value="WY">WY</option>                 
                        
                      
                    </select></li>
                    
                    
				
				
				<li><div class="error" id='zip_error' >Enter Zip</div>
				<label>Zip:</label><input class="zipcode" type="text" name="zip" id="zip"  value="92705"></li>
            
            </ul>
        </div>

		<div class="separator-line"></div>

		
		<div id="yconfirm">
		  <h4 style="margin-bottom: 0px">Shipping Address</h4>
		  <p><input type="checkbox" name="" id="checkbox" value="1" onClick='up_ship_form()'> (same as billing)</p>
		  
		  <ul>

			<li><div class="error" id='firstname_s_error' >Enter First Name</div>
			<label>First Name:</label><input type="text"  id="firstname_s" name="firstname_s"  value="Mark"></li>
			
			<li><div class="error" id='lastname_s_error' >Enter Last Name</div>
			<label>Last Name:</label><input type="text"  id="lastname_s" name="lastname_s"  value="10942 Lake Court Road"></li>
			
			<li><div class="error" id='address_s_error' >Enter Address</div>
			<label>Address:</label><input type="text"  name="address_s" id="address_s"  value="10942 Lake Court Road"></li>
			
			<li><label>Address 2 *</label><input type="text"  name="address_s_2" id="address_s_2"  value=""></li>
			
			<li><div class="error" id='city_s_error' >Enter City</div>
			<label>City:</label><input type="text"  name="city_s" id="city_s"  value="North Tustin"></li>
			
			<li><div class="error" id='state_s_error' >Select State</div>
			<label>State:</label><select id="state_s" name="state_s"  class="state">

                 <option value="CA">CA</option>						<option value="AL">AL</option>
                        <option value="AK">AK</option>
                        <option value="AZ">AZ</option>
                        <option value="AR">AR</option>
                        <option value="CA">CA</option>
                        <option value="CO">CO</option>
                        <option value="CT">CT</option>
                        <option value="DC">DC</option>
                        
                        <option value="DE">DE</option>
                        <option value="FL">FL</option>
                        <option value="GA">GA</option>
                        <option value="HI">HI</option>
                        <option value="ID">ID</option>
                        <option value="IL">IL</option>
                        <option value="IN">IN</option>
                        <option value="IA">IA</option>
                        <option value="KS">KS</option>
                        
                        <option value="KY">KY</option>
                        <option value="LA">LA</option>
                        <option value="ME">ME</option>
                        <option value="MD">MD</option>
                        <option value="MA">MA</option>
                        <option value="MI">MI</option>
                        <option value="MN">MN</option>
                        <option value="MS">MS</option>
                        <option value="MO">MO</option>
                        
                        <option value="MT">MT</option>
                        <option value="NE">NE</option>
                        <option value="NV">NV</option>
                        <option value="NH">NH</option>
                        <option value="NJ">NJ</option>
                        <option value="NM">NM</option>
                        <option value="NY">NY</option>
                        <option value="NC">NC</option>
                        <option value="ND">ND</option>
                        
                        <option value="OH">OH</option>
                        <option value="OK">OK</option>
                        <option value="OR">OR</option>
                        <option value="PA">PA</option>
                        <option value="RI">RI</option>
                        <option value="SC">SC</option>
                        <option value="SD">SD</option>
                        <option value="TN">TN</option>
                        <option value="TX">TX</option>
                        
                        <option value="UT">UT</option>
                        <option value="VT">VT</option>
                        <option value="VA">VA</option>
                        <option value="WA">WA</option>
                        <option value="WV">WV</option>
                        <option value="WI">WI</option>
                        <option value="WY">WY</option>
                    </select> </li>
                    

	        <li><div class="error" id='zip_s_error' >Enter Zip</div>
            <label>Zip:</label><input class="zipcode" type="text"  name="zip_s" id="zip_s"  value="92705"></li>
            
        </ul>
      </div>


	<div class="separator-line"></div>
                    
		<div id="yconfirm">
         <h4>Credit card details</h4>
            <ul>
            
            <li><div class="error" id='cc_type_error' >Select Credit Card Type</div>
              <label>Credit Card Type:</label><select id="cc_type" name="cc_type" class="card">

						<option value="" >- Select Credit Card Type -</option>
                        <option value="Visa">Visa</option>
						<option value="Mastercard">Mastercard</option>
						<option value="Discover">Discover</option>    
						<option value="American Express">American Express</option>   
                    </select><br />
                <label>&nbsp;</label><img src="assets/images/cart/icon-creditcards_127x23.gif" alt="Mastercard, Visa, Discover, Amex" style="padding-top: 3px"/></li>
              
            <li><div class="error" id='ccNumInvalid_error' >Invalid Card Number</div>
				<div class="error" id='ccNum_error' >Enter Card Number</div>
				<label>Credit Card Number:</label><input type="text" id="ccNum" name="ccNum" value="" />
				<!-- <span>Example: 1234 1234 1234 1234</span>	--></li>
              
			<li><div class="error" id='ccvv_error' >Enter CVV2 Number</div>
                <label>Credit Verification Code:</label><input class="cvv" type="text" id="ccvv" name="ccvv" value="" maxlength="4" /><br />
                <label>&nbsp;</label><img src="assets/images/cart//icon-cvc_37x23.gif" width="37" height="23" alt="CVC example" style="padding-top: 3px" /></li>
				
				
			<li><label class="cc">Expiration Date:*</label>
					<select id="card_expire_month" name="card_expire_month" class="date">

						  <option value="01">Jan</option>
						  <option value="02">Feb</option>
	
						  <option value="03">Mar</option>
						  <option value="04">Apr</option>
						  <option value="05">May</option>
						  <option value="06">Jun</option>
						  <option value="07">Jul</option>
						  <option value="08">Aug</option>
	
						  <option value="09">Sep</option>
						  <option value="10">Oct</option>
						  <option value="11">Nov</option>
						  <option value="12">Dec</option>

                        
                     </select>

                    <select id="card_expire_year" name="card_expire_year" class="date">
              
                     <option value="11" >2011</option><option value="12" >2012</option><option value="13" >2013</option><option value="14" >2014</option><option value="15" >2015</option><option value="16" >2016</option><option value="17" >2017</option><option value="18" >2018</option><option value="19" >2019</option>                        
                    </select></li>
	
			</ul>
        </div>
	
	
	
	<div class="separator-line"></div>

	<div id="yconfirm">

    <ul>
        <input type="hidden" name="attempts" value="" />
        
        <li><div class="error" id="checkerror_error">Please check for errors above in red</div>
        <label>&nbsp;</label><input type="submit" name="payment" id="process_button" value="Go to Verify Order" /></li>
     </ul>

  </div>


	</form>
	</div>
	
