<link rel="stylesheet" type="text/css" href="assets/admin-tools/admin-forms/css/admin-forms.css">
<!-- Order Form 1 -->
<div class="admin-form theme-success" id="order1">
<div class="panel panel-success heading-border">
<div class="panel-heading">
<span class="panel-title"><i class="fa fa-truck"></i>Confirm order
</span>
</div>
<!-- end .form-header section -->
<form method="post" action="/" id="form-order1">
<div class="panel-body p25">
<div class="section-divider mt20 mb40">
<span>You are ordering for</span>
</div>
<!-- .section-divider -->
<div class="section row hidden">
<div class="col-md-6">
<div class="section">
<div class="price-box">
<h4><sup>$</sup>29
<span class="per-month">/month</span>
</h4>
<h5>Starter</h5>
<div class="spacer mt20 mb20"></div>
<p>For those looking for something simple to get started.</p>
<div class="spacer mt20 mb20"></div>
<a href="#" class="button block pushed expand"> Learn more </a>
</div>
<!-- end .colm-box section -->
</div>
<!-- end .section section -->
<div class="section align-center">
<label class="switch">
<input type="radio" name="order" id="order1">
<label for="order1" data-on="YES" data-off="NO"></label>
<span>Select</span>
</label>
</div>
<!-- end .tc section -->
</div>
<!-- end .colm section -->
<div class="col-md-6">
<div class="section">
<div class="price-box selected-box">
<div class="ribbon-large">
<div class="ribbon-inner">POPULAR</div>
</div>
<h4><sup>$</sup>179
<span class="per-month">/month</span>
</h4>
<h5>Professional</h5>
<div class="spacer mt20 mb20"></div>
<p>For large enterprises selling over one million plus a year.</p>
<div class="spacer mt20 mb20"></div>
<a href="#" class="button btn-primary block pushed expand"> Learn more </a>
</div>
<!-- end .colm-box section -->
</div>
<!-- end .section section -->
<div class="section align-center">
<label class="switch">
<input type="radio" name="order2" id="orderid2" checked>
<label for="orderid2" data-on="YES" data-off="NO"></label>
<span>Select</span>
</label>
</div>
<!-- end .tc section -->
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section row">
<div class="col-md-6">
<label for="pname" class="field prepend-icon">
<input type="text" name="pname" id="pname" class="gui-input" placeholder="Your names...">
<label for="pname" class="field-icon"><i class="fa fa-user"></i>
</label>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<label for="email" class="field prepend-icon">
<input type="email" name="email" id="email" class="gui-input" placeholder="Email address">
<label for="email" class="field-icon"><i class="fa fa-envelope"></i>
</label>
</label>
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section row">
<div class="col-md-6">
<label for="mobile" class="field prepend-icon">
<input type="tel" name="mobile" id="mobile" class="gui-input" placeholder="Tel / moble">
<label for="mobile" class="field-icon"><i class="fa fa-phone-square"></i>
</label>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<label for="firstaddr" class="field prepend-icon">
<input type="text" name="firstaddr" id="firstaddr" class="gui-input" placeholder="Street address">
<label for="firstaddr" class="field-icon"><i class="fa fa-map-marker"></i>
</label>
</label>
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section row">
<div class="col-md-6">
<label for="zip" class="field prepend-icon">
<input type="text" name="zip" id="zip" class="gui-input" placeholder="Zip">
<label for="zip" class="field-icon"><i class="fa fa-certificate"></i>
</label>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<label for="city" class="field prepend-icon">
<input type="text" name="city" id="city" class="gui-input" placeholder="City">
<label for="city" class="field-icon"><i class="fa fa-building-o"></i>
</label>
</label>
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section row">
<div class="col-md-6">
<label class="field select">
<select id="location" name="location">
<option value="">Select country...</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan Republic</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BB">Barbados</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BR">Brazil</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="C2">China Worldwide</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="GA">Gabon Republic</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea Bissau</option>
<option value="GY">Guyana</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</option>
<option value="LV">Latvia</option>
<option value="LS">Lesotho</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="CG">Republic of the Congo</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts and Nevis Anguilla</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="LC">St. Lucia</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UY">Uruguay</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City State</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
</select>
<i class="arrow double"></i>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<label for="states" class="field select">
<select id="states" name="states">
<option value="">Choose state</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Las Vegas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
<i class="arrow double"></i>
</label>
</div>
<!-- end .colm6 section -->
</div>
<div class="section-divider mt50 mb40">
<span>Payment Details</span>
</div>
<!-- .section-divider -->
<div class="section mb10">
<p class="small-text text-muted">Please choose a preferred method of payment below</p>
</div>
<!-- end section -->
<div class="section mb25">
<label class="option">
<input type="radio" name="payment" checked>
<span class="radio"></span>Credit Card</label>
<label class="option">
<input type="radio" name="payment">
<span class="radio"></span>Paypal</label>
<label class="option">
<input type="radio" name="payment">
<span class="radio"></span>Check</label>
</div>
<!-- end section -->
<div class="section row">
<div class="col-md-6">
<label for="cardname" class="field prepend-icon">
<input type="text" name="cardname" id="cardname" class="gui-input" placeholder="Name on card...">
<label for="cardname" class="field-icon"><i class="fa fa-user"></i>
</label>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<label for="cardno" class="field prepend-icon">
<input type="text" name="cardno" id="lastname" class="gui-input" placeholder="Card number...">
<label for="cardno" class="field-icon"><i class="fa fa-credit-card"></i>
</label>
</label>
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section row">
<div class="col-md-6">
<label for="cardmonth" class="field select">
<select id="cardmonth" name="cardmonth">
<option value="">Expiry month...</option>
<option value="01">01 - Jan</option>
<option value="02">02 - Feb</option>
<option value="03">03 - Mar</option>
<option value="04">04 - Apr</option>
<option value="05">05 - May</option>
<option value="06">06 - Jun</option>
<option value="07">07 - Jul</option>
<option value="08">08 - Aug</option>
<option value="09">09 - Sep</option>
<option value="10">10 - Oct</option>
<option value="11">11 - Nov</option>
<option value="12">12 - Dec</option>
</select>
<i class="arrow double"></i>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<label class="field select">
<select id="cardyear" name="cardyear">
<option value="">Expiry year...</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
</select>
<i class="arrow double"></i>
</label>
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section row">
<div class="col-md-6">
<label for="secno" class="field prepend-icon">
<input type="text" name="secno" id="secno" class="gui-input" placeholder="Security number...">
<b class="tooltip tip-left-top"><em> This is a four diigit number at the back of your card </em></b>
<label for="secno" class="field-icon"><i class="fa fa-barcode"></i>
</label>
</label>
</div>
<!-- end section -->
<div class="col-md-6">
<p>
<a href="#" class="theme-link field-align"> What is this? </a>
</p>
</div>
<!-- end section -->
</div>
<!-- end section row section -->
<div class="section">
<label class="option">
<input type="checkbox" name="info" checked>
<span class="checkbox"></span>Save my information
<em class="small-text text-muted">(Its safe & secure)</em>
</label>
</div>
<!-- end section -->
</div>
<!-- end .form-body section -->
<div class="panel-footer align-right">
<button type="submit" class="button btn-primary">Place Order</button>
<button type="reset" class="button">Cancel Order</button>
</div>
<!-- end .form-footer section -->
</form>
</div>
<!-- end .admin-form section -->
</div>
<!-- end: .admin-form -->