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<?php require 'header.php'; ?>
<section id="content" class="sbr">
<div class="menu-shadow"></div>
<div class="container clearfix">
<div class="page-header clearfix" style="margin-bottom: 20px;">
<h1>Members Only Registration</h1>
<div class="line"></div>
</div>
<!--/ .page-header-->
<section id="main" class="twelve columns">
<article class="entry clearfix">
<div class="entry-body">
<form action="adduser.php" method="post">
<input type="hidden" name="zip" value="">
<input type="hidden" name="homephone" value="">
<table><tr><td>
<table border="0" width="425">
<tr><td>
<tr>
<td valign="top"><b><font face="Arial" size="+0">Name:</font></b></td>
<td valign="top"><input name="fname" maxlength="30" type="text" size="11" placeholder="First Name"> <input name="lname" maxlength="30" type="text" size="13" placeholder="Last Name">
<input name="fName_required" type="hidden" value="You must enter your first name."></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">E-Mail Address:</font></b></td>
<td><input name="EMail" maxlength="70" type="text" size="30">
<input name="Email_required" type="hidden" value="You must enter your e-mail address."></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">Street Address:</font></b></td>
<td><input name="Address" type="text" size="30"><br>
<input name="Address2" type="text" size="30">
<input name="Address_required" type="hidden" value="You must enter your street address."></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">City:</font></b></td>
<td><input name="City" type="text" size="25">
<input name="city_required" type="hidden" value="You must enter your city."></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">State:</font></b></td>
<td><select size="1" name="State">
<option value=""></option>
<option value="AB">AB</option><option value="AE">AE</option><option value="AK">AK</option><option value="AL">AL</option><option value="AR">AR</option><option value="AS">AS</option><option value="AZ">AZ</option><option value="BC">BC</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="GU">GU</option><option value="HI">HI</option><option value="IA">IA</option><option value="ID">ID</option><option value="IL">IL</option><option value="IN">IN</option><option value="KS">KS</option><option value="KY">KY</option><option value="LA">LA</option><option value="MA">MA</option><option value="MB">MB</option><option value="MD">MD</option><option value="ME">ME</option><option value="MI">MI</option><option value="MN">MN</option><option value="MO">MO</option><option value="MP">MP</option><option value="MS">MS</option><option value="MT">MT</option><option value="NB">NB</option><option value="NC">NC</option><option value="ND">ND</option><option value="NE">NE</option><option value="NF">NF</option><option value="NH">NH</option><option value="NJ">NJ</option><option value="NM">NM</option><option value="NS">NS</option><option value="NT">NT</option><option value="NV">NV</option><option value="NY">NY</option><option value="OH">OH</option><option value="OK">OK</option><option value="ON">ON</option><option value="OR">OR</option><option value="PA">PA</option><option value="PE">PE</option><option value="PQ">PQ</option><option value="PR">PR</option><option value="PW">PW</option><option value="RI">RI</option><option value="SC">SC</option><option value="SD">SD</option><option value="SK">SK</option><option value="TN">TN</option><option value="TX">TX</option><option value="UT">UT</option><option value="VA">VA</option><option value="VI">VI</option><option value="VT">VT</option><option value="WA">WA</option><option value="WV">WV</option><option value="WI">WI</option><option value="WY">WY</option><option value="YT">YT</option>
</select></td>
</tr>
<tr>
<td valign="top"><b><font face="Arial" size="+0">Zip Code:</font></b></td>
<td><input name="Zip" type="text" size="14"></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">Country:</font></b></td>
<td><select size="1" name="Country">
<option value=""></option>
<option value="UNITED STATES">UNITED STATES</option>
<option value="CANADA">CANADA</option>
<option value="MEXICO">MEXICO</option>
<option value="AUSTRALIA">AUSTRALIA</option>
<option value="AUSTRIA">AUSTRIA</option>
<option value="BELGIUM">BELGIUM</option>
<option value="BRAZIL">BRAZIL</option>
<option value="CHINA, PEOPLES REPUBLIC">CHINA, PEOPLES REPUBLIC</option>
<option value="DENMARK">DENMARK</option>
<option value="ENGLAND">ENGLAND</option>
<option value="FINLAND">FINLAND</option>
<option value="FRANCE">FRANCE</option>
<option value="GERMANY">GERMANY</option>
<option value="GREECE">GREECE</option>
<option value="HONG KONG">HONG KONG</option>
<option value="INDIA">INDIA</option>
<option value="IRELAND">IRELAND</option>
<option value="ISRAEL">ISRAEL</option>
<option value="ITALY">ITALY</option>
<option value="JAPAN">JAPAN</option>
<option value="NETHERLANDS">NETHERLANDS</option>
<option value="NEW ZEALAND">NEW ZEALAND</option>
<option value="NORTHERN IRELAND">NORTHERN IRELAND</option>
<option value="NORWAY">NORWAY</option>
<option value="POLAND">POLAND</option>
<option value="PORTUGAL">PORTUGAL</option>
<option value="RUSSIA">RUSSIA</option>
<option value="SCOTLAND">SCOTLAND</option>
<option value="SOUTH AFRICA">SOUTH AFRICA</option>
<option value="SPAIN">SPAIN</option>
<option value="SWEDEN">SWEDEN</option>
<option value="SWITZERLAND">SWITZERLAND</option>
<option value="WALES">WALES</option>
</select></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">Phone Number: </b></td>
<td><input name="Phone" type="text" size="14"></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">Member Number: </b><font size="-1"><br> (you MUST include the valid MCIFA member number from<br> your membership card)</font></b></td>
<td><input name="Member" type="text" size="14"></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">Password: </b><font size="-1">(please choose a personal password)</font></b></td>
<td><input name="Password" type="text" size="14"></td>
</tr>
<tr>
<td><b><font face="Arial" size="+0">List in Member Directory: </b><br>
<font face="arial" size="-1">(Online and Print)</font></td>
<td> <select name="List" size="1">
<option>Yes</option>
<option>No</option>
</select></td>
</tr>
</table>
<center><input type="submit" value="Register"></form>
</td></tr></table>
</div>
<!--/ .entry-body-->
</article>
<!--/ .entry-->
</section> <!--/ #main-->
<?php require 'sidebar.php'; ?>
<?php require 'footer.php'; ?>