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index2.html
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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en">
<head>
<title></title>
<meta http-equiv="Content-Type" content="text/html;charset=UTF-8" />
<link rel="stylesheet" type="text/css" href="css/style.css" media="all" />
<link href="css/cal.css" rel="stylesheet" type="text/css" />
<script type="text/javascript" src="js/Validation.js"></script>
<script type="text/javascript" src="js/functions.js"></script>
<script language="javascript" src="js/tabbing.js"></script>
</head>
<body onLoad="start_cal();init();">
<div >
<div id="form-wrap" style="margin:0 auto;">
<form action="process.php" method="post" id="applicant" name="applicant" onSubmit="return submit_form();">
<fieldset>
<strong class="form-title">Get cash now! up to $1000 cash loan</strong>
<div class="form-block">
<p>
<span class="half m-r-8">
<label>First name:</label>
<input type='text' maxlength=32 id="first_name" name="first_name" chkType="alpha" chkTitle="First Name" chkRequired=true />
</span>
<span class="half">
<label>Last Name:</label>
<input type='text' maxlength=32 id="last_name" name="last_name" chkType="alpha" chkTitle="Last Name" chkRequired=true />
</span>
</p>
<p>
<span class="half m-r-8">
<label>Email:</label>
<input name="email" size="20" maxlength="70" id="email" value="" type="text" chkTitle="Email" chkRequired="true" chkMinLength="5" chkType="email" />
</span>
<span class="half">
<label>Home Phone:</label>
<input class="w-65 m-r-3" type="text" onChange="update_home_phone();" name="HomePhone1" maxlength="3" id="HomePhone1" value="" chkTitle="Home Phone (Part 1)" chkRequired="true" chkReqLength="3" chkType="num" next="HomePhone2" />
<input class="w-65 m-r-3" type="text" onChange="update_home_phone();" name="HomePhone2" maxlength="3" id="HomePhone2" value="" chkTitle="Home Phone (Part 2)" chkRequired="true" chkReqLength="3" chkType="num" next="HomePhone3" />
<input class="w-72" type="text" onChange="update_home_phone();" name="HomePhone3" maxlength="4" value="" id="HomePhone3" chkTitle="Home Phone (Part 3)" chkRequired="true" chkReqLength="4" chkType="num" next="address" />
<input name="home_phone" type="hidden" id="home_phone" />
</span>
</p>
<p>
<span class="total">
<label>Address:</label>
<input type='text' maxlength=60 id="address" name="address" chkTitle="Address" chkRequired=true />
</span>
</p>
<p>
<span class="third m-r-8">
<label>ZIP Code:</label>
<input name="zip" type='text' id="zip" maxlength=5 chkTitle="Zip" chkRequired=true next="months_at_residence" />
</span>
<span class="third m-r-8">
<label>Time at Address:</label>
<select class="w-165" name="months_at_residence" id="months_at_residence">
<option value="12">1 Year or less</option>
<option value="24">2 Years</option>
<option value="36">3 Years</option>
<option value="48">4 Years</option>
<option value="60">5 Years</option>
<option value="72">6 Years</option>
<option value="84">7 Years</option>
<option value="96">8 Years</option>
<option value="108">9 Years</option>
<option value="120">10+ Years</option>
</select>
</span>
<span class="third">
<label>Own/Rent:</label>
<select class="w-165" name="housing" id="housing">
<option value="rent" selected="selected">Rent</option>
<option value="own">Own</option>
</select>
</span>
</p>
<p>
<input type="radio" id="active_military1" name="active_military" value="true" />
<span class="radio-label">YES</span>
<input type="radio" id="active_military2" name="active_military" value="false" checked="checked" />
<span class="radio-label">NO</span>
<span class="text-wrap">Are you or are you the dependent of someone <br />employed by the US Military?</span>
</p>
</div><!--.form-block-->
<div class="form-block">
<strong class="form-block-title">What is your main source of income?</strong>
<p>
<span class="third m-r-8">
<label>Montly Income:</label>
<select class="w-165" id="monthly_income" name="monthly_income">
<option value="750">Less than $750</option>
<option value="1000">$751-$1000</option>
<option value="1250">$1001-$1250</option>
<option value="1500">$1251-$1500</option>
<option value="1750">$1501-$1750</option>
<option value="2000">$1751-$2000</option>
<option value="2250">$2001-$2250</option>
<option value="2500">$2251-$2500</option>
<option value="2750" selected="selected">$2501-$2750</option>
<option value="3000">$2751-$3000</option>
<option value="3250">$3001-$3250</option>
<option value="3500">$3251-$3500</option>
<option value="3750">$3501-$3750</option>
<option value="4000">$3751-$4000</option>
<option value="4250">$4001-$4250</option>
<option value="4500">$4251-$4500</option>
<option value="4750">$4501-$4750</option>
<option value="5000">$4751-$5000</option>
<option value="5250">$5001-$5250</option>
<option value="5500">$5251-$5500</option>
<option value="5750">$5501-$5750</option>
<option value="6000">$5751-$6000</option>
<option value="6001">More than $6000</option>
</select>
</span>
<span class="third m-r-8" style="width: 173px;" >
<label>Birth Date:</label>
<select class="w-53 m-r-3" onChange="update_birth_date();" name="BirthMonth" id="BirthMonth" chkRequired="true" chkMinLength="1" chkType="num" chkTitle="Birthday Month">
<option value="">MM</option>
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12">Dec</option>
</select>
<select class="w-53 m-r-3" onChange="update_birth_date();" name="BirthDay" id="BirthDay" chkRequired="true" chkMinLength="1" chkType="num" chkTitle="Birthday Day">
<option value="">DD</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select class="w-53" style="width: 58px; padding-left: 1px;" onChange="update_birth_date();" name="BirthYear" id="BirthYear" chkRequired="true" chkMinLength="1" chkType="num" chkTitle="Birthday Year">
<option value="">YYYY</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
</select><input type="hidden" id="birth_date" name="birth_date" />
</span>
<span class="third">
<label>SSN: (e.g. 123456789)</label>
<input type="text" class="w-55 m-r-3" maxlength="3" onChange="update_ssn();" name="ssn1" id="ssn1" value="" chkTitle="Social Security Number (Part 1)" chkRequired="true" chkReqLength="3" chkType="num" next="ssn2" />
<input type="text" class="w-45 m-r-3" maxlength="2" onChange="update_ssn();" name="ssn2" id="ssn2" value="" chkTitle="Social Security Number (Part 2)" chkRequired="true" chkReqLength="2" chkType="num" next="ssn3" />
<input type="text" class="w-65" onChange="update_ssn();" name="ssn3" maxlength="4" value="" id="ssn3" chkTitle="Social Security Number (Part 3)" chkRequired="true" chkReqLength="4" chkType="num" next="income_type" />
<input name="social_security_number" type="hidden" id="social_security_number" />
</span>
</p>
<p>
<span class="third m-r-8">
<label>Income source:</label>
<select class="w-165" id="income_type" name="income_type">
<option value="employment" selected="selected">Employment</option>
<option value="benefits">Benefits</option>
</select>
</span>
<span class="third m-r-8" style="width: 173px;">
<label>Employer Name:</label>
<input type="text" name="employer" style="width: 161px;" value="" maxlength="25" id="employer" chkTitle="employer Name" chkRequired="true" chkMinLength="4" />
</span>
<span class="third">
<label>Work Phone:</label>
<input type="text" class="w-w55 m-r-3" onChange="update_work_phone();" maxlength="3" name="EmployerPhone1" id="EmployerPhone1" chkTitle="Work Phone (Part 1)" chkRequired="true" chkReqLength="3" chkType="num" next="EmployerPhone2" value="" />
<input type="text" class="w-w45 m-r-3" onChange="update_work_phone();" maxlength="3" name="EmployerPhone2" id="EmployerPhone2" chkTitle="Work Phone (Part 2)" chkRequired="true" chkReqLength="3" chkType="num" next="EmployerPhone3" value="" />
<input type="text" class="w-w65" onChange="update_work_phone();" maxlength="4" name="EmployerPhone3" id="EmployerPhone3" chkTitle="Work Phone (Part 3)" chkRequired="true" chkReqLength="4" chkType="num" value="" next="pay_period" />
<input name="work_phone" type="hidden" id="work_phone" />
</span>
</p>
<p><span class="third m-r-8">
<label>Pay Period:</label>
<select class="w-165" name="pay_period">
<option value="weekly">Weekly</option>
<option value="biweekly" selected="selected">Bi-Weekly</option>
<option value="twice_monthly">Twice Monthly</option>
<option value="monthly">Monthly</option>
</select>
</span>
<span class="third m-r-8" style="width: 220px;">
<label>Next Pay Date:</label>
<select size="1" name="pd1m" id="pd1m" onchange="update_next_pay_date();" class="w-53 m-r-3">
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12">Dec</option>
</select>
<select size="1" name="pd1d" id="pd1d" onchange="update_next_pay_date();" class="w-53 m-r-3">
<option value="01">1</option>
<option value="02">2</option>
<option value="03">3</option>
<option value="04">4</option>
<option value="05">5</option>
<option value="06">6</option>
<option value="07">7</option>
<option value="08">8</option>
<option value="09">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select size="1" name="pd1y" id="pd1y" onchange="update_next_pay_date();" class="w-72">
</select><span class="calendar"><img src="img/calendar-bg.gif" border="0" alt onClick="openCal();" style="cursor:pointer;" ></span>
</span>
<div class="main_cal" style=" overflow: visible;z-index: 100; top: 15px; left: 240px;" id="calender_div" onMouseOver="close_cal=false;" onMouseOut="close_cal=true;"> </div>
</p>
</div><!--.form-block-->
<div class="form-block">
<strong class="form-block-title">Where should the money be deposited to?</strong>
<p>
<span class="third m-r-8">
<label>Bank Name:</label>
<input name="bank_name" value="" id="bank_name" type="text" chkTitle="Bank Name" chkRequired="true" chkMinLength="2" />
</span>
<span class="third m-r-8">
<label>Bank Account Type:</label>
<select id="account_type" name="account_type" class="w-165">
<option value="checking" selected="selected">Checking Account</option>
<option value="saving">Savings Account</option>
</select>
</span>
<span class="third">
<label>Direct Deposit:</label>
<select name="direct_deposit" class="w-165">
<option value="true">Direct Deposit</option>
<option value="false">Paper Check</option>
</select>
</span>
</p>
<p>
<span class="half m-r-8 w-253">
<label>Routing Number:<span class="tip"><a href="#" onclick="window.open('check.html','', 'height=560, width=600'); return false;">?</a></span></label>
<input name="routing_number" id="routing_number" maxlength="9" value="" chkTitle="Bank Routing Number" chkRequired="true" chkMinLength="9" chkType="num" type="text" next="account_number" />
</span>
<span class="half w-253">
<label>Account Number:<span class="tip"><a href="#" onclick="window.open('check.html','', 'height=560, width=600'); return false;">?</a></span></label>
<input name="account_number" value="" id="account_number" type="text" chkTitle="Account Number" chkType="num" chkRequired="true" chkMinLength="4" />
</span>
</p>
<p>
<span class="half m-r-8 w-253">
<label>Driver's Licence or State ID:</label>
<input name="driving_license_number" value="" id="driving_license_number" type="text" chkTitle="Driver's License Number" chkRequired="true" chkMinLength="5" />
</span>
<span class="half w-253">
<label>Issuing State:</label>
<select class="w-250" id="driving_license_state" name="driving_license_state">
<option value='AK'>AK</option>
<option value='AL'>AL</option>
<option value='AR'>AR</option>
<option value='AZ'>AZ</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='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='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='MS'>MS</option>
<option value='MT'>MT</option>
<option value='NC'>NC</option>
<option value='ND'>ND</option>
<option value='NE'>NE</option>
<option value='NH'>NH</option>
<option value='NJ'>NJ</option>
<option value='NM'>NM</option>
<option value='NV'>NV</option>
<option value='NY'>NY</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>
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