<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
"http://www.w3.org/TR/html4/loose.dtd">
<!-- www.ukbathroomcreations.com/customer_login/register/ -->
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<meta name="google-site-verification" content="ezxF_-OmrwaU2Qu5wTV0YHNCHP8DHFlmiyWvYKQuBFk" >
<title>Customer Login | UK Bathroom Creations</title>
<meta name="title" content="">
<meta name="keywords" content="">
<meta name="description" content="">
<meta name="copyright" content="UK Bathroom Creations">
<meta name="robots" content="">
<meta name="distribution" content="global">
<meta name="revisit-after" content=" days">
<meta name="google-site-verification" content="R12-HUrA-gzWvs5XPLyZlXzInnjhWjeosQ-6b3apjBE" />
</head>
<body>
<form action='/inc/modules/authentication/process_registration.php' method='post'>
<input type='hidden' name='fromRegForm' value=true><div class='reg_box'>
<span class='cn'>Company Details</span><ol><li><div style='width:200px;float:left;'>Company Name:</div>
<input type='text' name='ecomms_company_name' value=""></li></ol></div><div class='reg_box'>
<span class='cn'>Personal Details</span><ol><li class='red'> </li><li><div style='width:200px;float:left;'>Title:</div><select name='ecomms_title'><option value=""></option><option value="Mr" >Mr</option><option value="Mrs" >Mrs</option><option value="Miss" >Miss</option><option value="Ms" >Ms</option><option value="Dr" >Dr</option><option value="Other" >Other</option></select>
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>First Name:</div>
<input type='text' name='ecomms_first_name' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Last Name:</div>
<input type='text' name='ecomms_last_name' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Telephone:</div>
<input type='text' name='ecomms_telephone' value="">
<span style='color:green'> *</span></li><li><div style='width:200px;float:left;'>Mobile:</div>
<input type='text' name='ecomms_mobile' value="">
<span style='color:green'> *</span></li></ol></div><br ><div class='reg_box'>
<span class='cn'>Account Login Details</span><ol><li>Be sure to use a correct email address as we will send you an email to activate your account</li><li class='red'>Sorry your password is too short please specify a password longer than 8 characters </li><li><div style='width:200px;float:left;'>Email Address:</div>
<input type=text name='ecomms_email' value="[email protected]">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Password:</div>
<input type='password' name='ecomms_password' value="abcdef">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Confirm password:</div>
<input type='password' name='ecomms_password_confirm' value="abcdef">
<span class='red'> *</span></li></ol></div><br ><div class='reg_box'>
<span class='cn'>Address Details</span><ol><li class='red'> </li><li><div style='width:200px;float:left;'>Address1:</div>
<input type='text' name='ecomms_address1' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Address2:</div>
<input type='text' name='ecomms_address2' value=""></li><li><div style='width:200px;float:left;'>Town / City:</div>
<input type='text' name='ecomms_town' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>County:</div>
<input type='text' name='ecomms_county' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Postcode:</div>
<input type='text' name='ecomms_postcode' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Country:</div><select name='ecomms_country'><option value='224' >United Kingdom</option></select><li>
<input type='checkbox' value='1' name='delivery_address' onclick="if(this.checked==true){document.getElementById('del').style.display='inline';} else {document.getElementById('del').style.display='none';}" > specify a different delivery address</li></ol></div><br ><div class='reg_box' style='display:none;width:702px;' id='del'>
<span class='cn'>Delivery Address Details (if different from above)</span><ol><li class='red'> </li><li><div style='width:200px;float:left;'>Title:</div><select name='del_title'><option value=""></option><option value="Mr" >Mr</option><option value="Mrs" >Mrs</option><option value="Miss" >Miss</option><option value="Ms" >Ms</option><option value="Dr" >Dr</option><option value="Other" >Other</option></select>
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>First Name:</div>
<input type='text' name='del_first_name' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Last Name:</div>
<input type='text' name='del_last_name' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Telephone:</div>
<input type='text' name='del_telephone' value="">
<span style='color:green'> *</span></li><li><div style='width:200px;float:left;'>Mobile:</div>
<input type='text' name='del_mobile' value="">
<span style='color:green'> *</span></li><li> </li><li><div style='width:200px;float:left;'>Address1:</div>
<input type='text' name='del_address1' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Address2:</div>
<input type='text' name='del_address2' value=""></li><li><div style='width:200px;float:left;'>Town / City:</div>
<input type='text' name='del_town' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>County:</div>
<input type='text' name='del_county' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Postcode:</div>
<input type='text' name='del_postcode' value="">
<span class='red'> *</span></li><li><div style='width:200px;float:left;'>Country:</div><select name='ecomms_del_country'><option value='224' >United Kingdom</option></select></ol></div><div class='reg_box'><ol><li>
<input type='submit' value='Register'></li></ol></div>
</form>
</body>
</html>
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