universalunioncapital.xyz Open in urlscan Pro
198.54.115.107  Public Scan

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1 forms found in the DOM

POST #

<form action="#" class="form-register" method="post" enctype="multipart/form-data" id="acclogin">
  <div id="form-total">
    <!-- SECTION 1 -->
    <section style="width:100%; align:center; padding:10px;">
      <div class="inner">
        <div class="errorMessage" align="center">&nbsp;</div>
        <div class="wizard-header">
          <h3 class="heading">Account Information</h3>
          <p>Please enter your information and proceed to the next step so we can build your accounts. </p>
        </div>
        <h3 style="font-weight:700; color:Purple;">Basic User information </h3>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_firstname">
              <fieldset>
                <legend>First Name</legend>
                <input type="text" class="form-control" id="last-name" name="firstname" autocomplete="off" placeholder="First Name" required="">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Firstname is required.</span>
              <span class="textfieldMinCharsMsg">at least 6 characters.</span>
            </span>
          </div>
          <div class="form-holder">
            <span id="sprytf_lastname">
              <fieldset>
                <legend>Last Name</legend>
                <input type="text" class="form-control" id="last-name" name="lastname" autocomplete="off" placeholder="Last Name" required="">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">required.</span>
              <span class="textfieldMinCharsMsg">min 6 characters.</span>
            </span>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_email">
              <fieldset>
                <legend>Your Email</legend>
                <input type="text" name="email" id="your_email" class="form-control" pattern="[^@]+@[^@]+.[a-zA-Z]{2,6}" autocomplete="off" placeholder="example@email.com" required="">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Email is required.</span>
              <span class="textfieldInvalidFormatMsg">Enter valid email</span>
            </span>
          </div>
          <div class="form-holder">
            <span id="sprytf_phone">
              <fieldset>
                <legend>Phone Number</legend>
                <input type="text" class="form-control" id="phone" name="phone" autocomplete="off" placeholder="+18655356754" required="">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Phone Number is required.</span>
            </span>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_dob">
              <fieldset>
                <legend>Date of Birth</legend>
                <input type="date" class="form-control" id="first-name" name="dob" autocomplete="off" placeholder="Date of Birth" required="">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Date of Birth is required.</span>
              <span class="textfieldInvalidFormatMsg">enter a valid date (mm/dd/yyyy).</span>
            </span>
          </div>
          <div class="form-holder">
            <fieldset>
              <legend>National ID</legend>
              <input type="text" class="form-control" id="last-name" name="" autocomplete="off" placeholder="National ID NO.">
            </fieldset>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_lastname">
              <fieldset>
                <legend>Profile Picture</legend>
                <input type="file" class="form-control" id="first-name" name="pic" required="">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Picture is required.</span>
            </span>
          </div>
          <div class="form-holder">
            <span id="spryselect_gender">
              <legend>Gender</legend>
              <select name="gender" id="gender">
                <option value="">Please select your gender</option>
                <option value="Male">Male</option>
                <option value="Female">Female</option>
              </select>
              <br>
              <span class="selectRequiredMsg">Please select your gender.</span>
            </span>
          </div>
        </div>
        <div class="form-row">
          <script type="text/javascript" src="reg-assets/js/countries.js"></script>
          <div class="form-holder">
            <span>
              <legend>Country</legend>
              <select name="country" id="country">
                <option value="-1">Select Country</option>
                <option value="Afghanistan">Afghanistan</option>
                <option value="Albania">Albania</option>
                <option value="Algeria">Algeria</option>
                <option value="American Samoa">American Samoa</option>
                <option value="Angola">Angola</option>
                <option value="Anguilla">Anguilla</option>
                <option value="Antartica">Antartica</option>
                <option value="Antigua and Barbuda">Antigua and Barbuda</option>
                <option value="Argentina">Argentina</option>
                <option value="Armenia">Armenia</option>
                <option value="Aruba">Aruba</option>
                <option value="Ashmore and Cartier Island">Ashmore and Cartier Island</option>
                <option value="Australia">Australia</option>
                <option value="Austria">Austria</option>
                <option value="Azerbaijan">Azerbaijan</option>
                <option value="Bahamas">Bahamas</option>
                <option value="Bahrain">Bahrain</option>
                <option value="Bangladesh">Bangladesh</option>
                <option value="Barbados">Barbados</option>
                <option value="Belarus">Belarus</option>
                <option value="Belgium">Belgium</option>
                <option value="Belize">Belize</option>
                <option value="Benin">Benin</option>
                <option value="Bermuda">Bermuda</option>
                <option value="Bhutan">Bhutan</option>
                <option value="Bolivia">Bolivia</option>
                <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
                <option value="Botswana">Botswana</option>
                <option value="Brazil">Brazil</option>
                <option value="British Virgin Islands">British Virgin Islands</option>
                <option value="Brunei">Brunei</option>
                <option value="Bulgaria">Bulgaria</option>
                <option value="Burkina Faso">Burkina Faso</option>
                <option value="Burma">Burma</option>
                <option value="Burundi">Burundi</option>
                <option value="Cambodia">Cambodia</option>
                <option value="Cameroon">Cameroon</option>
                <option value="Canada">Canada</option>
                <option value="Cape Verde">Cape Verde</option>
                <option value="Cayman Islands">Cayman Islands</option>
                <option value="Central African Republic">Central African Republic</option>
                <option value="Chad">Chad</option>
                <option value="Chile">Chile</option>
                <option value="China">China</option>
                <option value="Christmas Island">Christmas Island</option>
                <option value="Clipperton Island">Clipperton Island</option>
                <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
                <option value="Colombia">Colombia</option>
                <option value="Comoros">Comoros</option>
                <option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
                <option value="Congo, Republic of the">Congo, Republic of the</option>
                <option value="Cook Islands">Cook Islands</option>
                <option value="Costa Rica">Costa Rica</option>
                <option value="Cote d'Ivoire">Cote d'Ivoire</option>
                <option value="Croatia">Croatia</option>
                <option value="Cuba">Cuba</option>
                <option value="Cyprus">Cyprus</option>
                <option value="Czeck Republic">Czeck Republic</option>
                <option value="Denmark">Denmark</option>
                <option value="Djibouti">Djibouti</option>
                <option value="Dominica">Dominica</option>
                <option value="Dominican Republic">Dominican Republic</option>
                <option value="Ecuador">Ecuador</option>
                <option value="Egypt">Egypt</option>
                <option value="El Salvador">El Salvador</option>
                <option value="Equatorial Guinea">Equatorial Guinea</option>
                <option value="Eritrea">Eritrea</option>
                <option value="Estonia">Estonia</option>
                <option value="Ethiopia">Ethiopia</option>
                <option value="Europa Island">Europa Island</option>
                <option value="Falkland Islands (Islas Malvinas)">Falkland Islands (Islas Malvinas)</option>
                <option value="Faroe Islands">Faroe Islands</option>
                <option value="Fiji">Fiji</option>
                <option value="Finland">Finland</option>
                <option value="France">France</option>
                <option value="French Guiana">French Guiana</option>
                <option value="French Polynesia">French Polynesia</option>
                <option value="French Southern and Antarctic Lands">French Southern and Antarctic Lands</option>
                <option value="Gabon">Gabon</option>
                <option value="Gambia, The">Gambia, The</option>
                <option value="Gaza Strip">Gaza Strip</option>
                <option value="Georgia">Georgia</option>
                <option value="Germany">Germany</option>
                <option value="Ghana">Ghana</option>
                <option value="Gibraltar">Gibraltar</option>
                <option value="Glorioso Islands">Glorioso Islands</option>
                <option value="Greece">Greece</option>
                <option value="Greenland">Greenland</option>
                <option value="Grenada">Grenada</option>
                <option value="Guadeloupe">Guadeloupe</option>
                <option value="Guam">Guam</option>
                <option value="Guatemala">Guatemala</option>
                <option value="Guernsey">Guernsey</option>
                <option value="Guinea">Guinea</option>
                <option value="Guinea-Bissau">Guinea-Bissau</option>
                <option value="Guyana">Guyana</option>
                <option value="Haiti">Haiti</option>
                <option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
                <option value="Holy See (Vatican City)">Holy See (Vatican City)</option>
                <option value="Honduras">Honduras</option>
                <option value="Hong Kong">Hong Kong</option>
                <option value="Howland Island">Howland Island</option>
                <option value="Hungary">Hungary</option>
                <option value="Iceland">Iceland</option>
                <option value="India">India</option>
                <option value="Indonesia">Indonesia</option>
                <option value="Iran">Iran</option>
                <option value="Iraq">Iraq</option>
                <option value="Ireland">Ireland</option>
                <option value="Ireland, Northern">Ireland, Northern</option>
                <option value="Israel">Israel</option>
                <option value="Italy">Italy</option>
                <option value="Jamaica">Jamaica</option>
                <option value="Jan Mayen">Jan Mayen</option>
                <option value="Japan">Japan</option>
                <option value="Jarvis Island">Jarvis Island</option>
                <option value="Jersey">Jersey</option>
                <option value="Johnston Atoll">Johnston Atoll</option>
                <option value="Jordan">Jordan</option>
                <option value="Juan de Nova Island">Juan de Nova Island</option>
                <option value="Kazakhstan">Kazakhstan</option>
                <option value="Kenya">Kenya</option>
                <option value="Kiribati">Kiribati</option>
                <option value="Korea, North">Korea, North</option>
                <option value="Korea, South">Korea, South</option>
                <option value="Kuwait">Kuwait</option>
                <option value="Kyrgyzstan">Kyrgyzstan</option>
                <option value="Laos">Laos</option>
                <option value="Latvia">Latvia</option>
                <option value="Lebanon">Lebanon</option>
                <option value="Lesotho">Lesotho</option>
                <option value="Liberia">Liberia</option>
                <option value="Libya">Libya</option>
                <option value="Liechtenstein">Liechtenstein</option>
                <option value="Lithuania">Lithuania</option>
                <option value="Luxembourg">Luxembourg</option>
                <option value="Macau">Macau</option>
                <option value="Macedonia, Former Yugoslav Republic of">Macedonia, Former Yugoslav Republic of</option>
                <option value="Madagascar">Madagascar</option>
                <option value="Malawi">Malawi</option>
                <option value="Malaysia">Malaysia</option>
                <option value="Maldives">Maldives</option>
                <option value="Mali">Mali</option>
                <option value="Malta">Malta</option>
                <option value="Man, Isle of">Man, Isle of</option>
                <option value="Marshall Islands">Marshall Islands</option>
                <option value="Martinique">Martinique</option>
                <option value="Mauritania">Mauritania</option>
                <option value="Mauritius">Mauritius</option>
                <option value="Mayotte">Mayotte</option>
                <option value="Mexico">Mexico</option>
                <option value="Micronesia, Federated States of">Micronesia, Federated States of</option>
                <option value="Midway Islands">Midway Islands</option>
                <option value="Moldova">Moldova</option>
                <option value="Monaco">Monaco</option>
                <option value="Mongolia">Mongolia</option>
                <option value="Montserrat">Montserrat</option>
                <option value="Morocco">Morocco</option>
                <option value="Mozambique">Mozambique</option>
                <option value="Namibia">Namibia</option>
                <option value="Nauru">Nauru</option>
                <option value="Nepal">Nepal</option>
                <option value="Netherlands">Netherlands</option>
                <option value="Netherlands Antilles">Netherlands Antilles</option>
                <option value="New Caledonia">New Caledonia</option>
                <option value="New Zealand">New Zealand</option>
                <option value="Nicaragua">Nicaragua</option>
                <option value="Niger">Niger</option>
                <option value="Nigeria">Nigeria</option>
                <option value="Niue">Niue</option>
                <option value="Norfolk Island">Norfolk Island</option>
                <option value="Northern Mariana Islands">Northern Mariana Islands</option>
                <option value="Norway">Norway</option>
                <option value="Oman">Oman</option>
                <option value="Pakistan">Pakistan</option>
                <option value="Palau">Palau</option>
                <option value="Panama">Panama</option>
                <option value="Papua New Guinea">Papua New Guinea</option>
                <option value="Paraguay">Paraguay</option>
                <option value="Peru">Peru</option>
                <option value="Philippines">Philippines</option>
                <option value="Pitcaim Islands">Pitcaim Islands</option>
                <option value="Poland">Poland</option>
                <option value="Portugal">Portugal</option>
                <option value="Puerto Rico">Puerto Rico</option>
                <option value="Qatar">Qatar</option>
                <option value="Reunion">Reunion</option>
                <option value="Romainia">Romainia</option>
                <option value="Russia">Russia</option>
                <option value="Rwanda">Rwanda</option>
                <option value="Saint Helena">Saint Helena</option>
                <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
                <option value="Saint Lucia">Saint Lucia</option>
                <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
                <option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
                <option value="Samoa">Samoa</option>
                <option value="San Marino">San Marino</option>
                <option value="Sao Tome and Principe">Sao Tome and Principe</option>
                <option value="Saudi Arabia">Saudi Arabia</option>
                <option value="Scotland">Scotland</option>
                <option value="Senegal">Senegal</option>
                <option value="Seychelles">Seychelles</option>
                <option value="Sierra Leone">Sierra Leone</option>
                <option value="Singapore">Singapore</option>
                <option value="Slovakia">Slovakia</option>
                <option value="Slovenia">Slovenia</option>
                <option value="Solomon Islands">Solomon Islands</option>
                <option value="Somalia">Somalia</option>
                <option value="South Africa">South Africa</option>
                <option value="South Georgia and South Sandwich Islands">South Georgia and South Sandwich Islands</option>
                <option value="Spain">Spain</option>
                <option value="Spratly Islands">Spratly Islands</option>
                <option value="Sri Lanka">Sri Lanka</option>
                <option value="Sudan">Sudan</option>
                <option value="Suriname">Suriname</option>
                <option value="Svalbard">Svalbard</option>
                <option value="Swaziland">Swaziland</option>
                <option value="Sweden">Sweden</option>
                <option value="Switzerland">Switzerland</option>
                <option value="Syria">Syria</option>
                <option value="Taiwan">Taiwan</option>
                <option value="Tajikistan">Tajikistan</option>
                <option value="Tanzania">Tanzania</option>
                <option value="Thailand">Thailand</option>
                <option value="Tobago">Tobago</option>
                <option value="Toga">Toga</option>
                <option value="Tokelau">Tokelau</option>
                <option value="Tonga">Tonga</option>
                <option value="Trinidad">Trinidad</option>
                <option value="Tunisia">Tunisia</option>
                <option value="Turkey">Turkey</option>
                <option value="Turkmenistan">Turkmenistan</option>
                <option value="Tuvalu">Tuvalu</option>
                <option value="Uganda">Uganda</option>
                <option value="Ukraine">Ukraine</option>
                <option value="United Arab Emirates">United Arab Emirates</option>
                <option value="United Kingdom">United Kingdom</option>
                <option value="Uruguay">Uruguay</option>
                <option value="USA">USA</option>
                <option value="Uzbekistan">Uzbekistan</option>
                <option value="Vanuatu">Vanuatu</option>
                <option value="Venezuela">Venezuela</option>
                <option value="Vietnam">Vietnam</option>
                <option value="Virgin Islands">Virgin Islands</option>
                <option value="Wales">Wales</option>
                <option value="Wallis and Futuna">Wallis and Futuna</option>
                <option value="West Bank">West Bank</option>
                <option value="Western Sahara">Western Sahara</option>
                <option value="Yemen">Yemen</option>
                <option value="Yugoslavia">Yugoslavia</option>
                <option value="Zambia">Zambia</option>
                <option value="Zimbabwe">Zimbabwe</option>
              </select>
              <br>
            </span>
          </div>
          <div class="form-holder">
            <span>
              <legend>State</legend>
              <select name="state" id="state">
                <option value="">Please select State</option>
              </select>
              <br>
            </span>
            <script language="javascript">
              populateCountries("country", "state"); // first parameter is id of country drop-down and second parameter is id of state drop-down
              populateCountries("country2");
              populateCountries("country2");
            </script>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_city">
              <fieldset>
                <legend>City Name</legend>
                <input type="text" class="form-control" id="first-name" name="city" autocomplete="off" placeholder="City">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">City Name is required.</span>
            </span>
          </div>
          <div class="form-holder">
            <span id="spryta_address">
              <fieldset>
                <legend>Residential Address</legend>
                <input type="text" class="form-control" id="ssn" name="address" autocomplete="off" placeholder="Residential Address">
              </fieldset>
              <br>
              <span class="textareaRequiredMsg">Address is required.</span>
              <span class="textareaMinCharsMsg">Address must specify at least 10 characters.</span>
            </span>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_zip">
              <fieldset>
                <legend>Zipcode</legend>
                <input type="text" class="form-control" id="first-name" name="zipcode" autocomplete="off" placeholder="Zip/Postal Code">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Zip Code is required.</span>
            </span>
          </div>
          <div class="form-holder">
            <legend>Account Type</legend>
            <span id="spryselect_acctype">
              <select name="acctype" id="acctype">
                <option value="">Account Type</option>
                <option value="ChA">Checking Account</option>
                <option value="SA">Saving Account</option>
                <option value="FDA">Fixed Deposit Account</option>
                <option value="CA">Current Account</option>
                <option value="BA">Business Account</option>
              </select>
              <br>
              <span class="selectRequiredMsg">Please select Account Type.</span>
            </span>
          </div>
        </div>
        <h3 style="font-weight:700; color:red;">Security Details</h3>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprypwd">
              <fieldset>
                <legend>Password</legend>
                <input type="password" class="form-control" id="pass" name="password" autocomplete="off" placeholder="Account Password" required="">
              </fieldset>
              <br>
              <span class="passwordRequiredMsg">required.</span>
              <span class="passwordMinCharsMsg">min of 6 characters.</span>
              <span class="passwordMaxCharsMsg">max 10 characters.</span>
            </span>
          </div>
          <div class="form-holder">
            <span id="sprycpwd">
              <fieldset>
                <legend>Confirm Password</legend>
                <input type="password" class="form-control" id="last-name" name="cpassword" autocomplete="off" placeholder="Confirm A/C Password" required="">
              </fieldset>
              <br>
              <span class="confirmRequiredMsg">required.</span>
              <span class="confirmInvalidMsg">values don't match</span>
            </span>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_pin">
              <fieldset>
                <legend>A/C PIN</legend>
                <input type="password" class="form-control" id="first-name" autocomplete="off" name="pin" placeholder="Account PIN">
              </fieldset>
              <br>
              <span class="textfieldRequiredMsg">Pin is required.</span>
              <span class="textfieldMinCharsMsg">at least 4 characters.</span>
              <span class="textfieldMaxCharsMsg">max of 6 characters.</span>
              <span class="textfieldInvalidFormatMsg">Pin must be Integer.</span>
            </span>
          </div>
          <div class="form-holder">
            <span id="sprytf_cpin">
              <fieldset>
                <legend>Verify A/C PIN</legend>
                <input type="password" class="form-control" id="last-name" name="cpin" autocomplete="off" placeholder="Confirm A/C PIN">
              </fieldset>
              <br>
              <span class="confirmRequiredMsg">Confirm Password is required.</span>
              <span class="textfieldRequiredMsg">Account Pin is required.</span>
              <span class="confirmInvalidMsg">values don't match</span>
            </span>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <legend>Select Security Question One</legend>
            <select required="" name="q1">
              <option value="">Please Select Question One</option>
              <option value="What is your pet name?">What is your pet name?</option>
              <option value="What is your nick name?">What is your nick name?</option>
              <option value="What is the name of your first car?">What is the name of your first car?</option>
              <option value="when did you finish high school?">when did you finish high school?</option>
              <option value="your favorite music?">your favorite music?</option>
              <option value="your favorite movie?">your favorite movie</option>
              <option value="your favorite roll model?">your favorite role model</option>
              <option value="favorite state?">favorite state?</option>
            </select>
          </div>
          <div class="form-holder">
            <fieldset>
              <legend>Answer Question One</legend>
              <input type="text" class="form-control" id="first-name" autocomplete="off" name="ans1" placeholder="Answer to Security Question One">
            </fieldset>
            <br>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span>
              <legend>Select Security Question Two</legend>
              <select required="" name="q2">
                <option value="">Please Select Question Two</option>
                <option value="What is the name of the road you grew up on?">What is the name of the road you grew up on?</option>
                <option value="What is your mother’s maiden name?">What is your mother’s maiden name?</option>
                <option value="Where did you meet your spouse?">Where did you meet your spouse?</option>
                <option value="when did you finish high school?">when did you finish high school?</option>
                <option value="What is your favorite food?">What is your favorite food?</option>
                <option value=" What city were you born in?"> What city were you born in?</option>
                <option value=" Where is your favorite place to vacation?"> Where is your favorite place to vacation?</option>
                <option value="What was the first company that you worked for?">What was the first company that you worked for?</option>
              </select>
            </span>
            <br>
          </div>
          <div class="form-holder">
            <fieldset>
              <legend>Answer Question Two</legend>
              <input type="text" class="form-control" id="first-name" autocomplete="off" name="ans2" placeholder="Answer to Security Question Two">
            </fieldset>
            <br>
          </div>
        </div>
        <h3 style="font-weight:700; color:blue;">Employment Information (Optional)</h3>
        <div class="form-row">
          <div class="form-holder">
            <span>
              <fieldset>
                <legend>Name, and Address of Employer</legend>
                <input type="text" class="form-control" id="last-name" name="empname" autocomplete="off" placeholder="Name, &amp; Address of Employer">
              </fieldset>
            </span>
            <br>
          </div>
          <div class="form-holder">
            <span>
              <fieldset>
                <legend>Phone Number of Employer</legend>
                <input type="text" class="form-control" id="last-name" name="" autocomplete="off" placeholder="Phone Number of Employer">
              </fieldset>
            </span>
            <br>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <legend>Type of Employment</legend>
            <select name="emptype">
              <option value="">Select Type of Employment</option>
              <option value="Self Employed">Self Employed</option>
              <option value="Self Employed">Public/Government Office</option>
              <option value="Self Employed">Private/Partnership Office</option>
              <option value="Self Employed">Business/Sales</option>
              <option value="Self Employed">Trading/Market</option>
              <option value="Self Employed">Military/Paramilitary</option>
              <option value="Self Employed">Politician/Celebrity</option>
            </select>
            <br>
          </div>
          <div class="form-holder">
            <legend>Salary Range</legend>
            <select name="salary">
              <option value="">Select Salary Range</option>
              <option value="$100.00 - $500.00">$100.00 - $500.00</option>
              <option value="$700.00 - $1,000.00">$700.00 - $1,000.00</option>
              <option value="$1,000.00 - $2,000.00">$1,000.00 - $2,000.00</option>
              <option value="$2,000.00 - $5,000.00">$2,000.00 - $5,000.00</option>
              <option value="$5,000.00 - $10,000.00">$5,000.00 - $10,000.00</option>
              <option value="$15,000.00 - $20,000.00">$15,000.00 - $20,000.00</option>
              <option value="$25,000.00 - $30,000.00">$25,000.00 - $30,000.00</option>
              <option value="$30,000.00 - $70,000.00">$30,000.00 - $70,000.00</option>
              <option value="$80,000.00 - $140,000.00">$80,000.00 - $140,000.00</option>
              <option value="$150,000.00 - $300,000.00">$150,000.00 - $300,000.00</option>
              <option value="$300,000.00 - $1,000,000.00">$300,000.00 - $1,000,000.00</option>
            </select>
            <br>
          </div>
        </div>
        <h3 style="font-weight:700; color:green;">Registered Next of Kin</h3>
        <div class="form-row">
          <div class="form-holder">
            <span>
              <fieldset>
                <legend>Beneficiary Legal Name</legend>
                <input type="text" name="bname" class="form-control" autocomplete="off" placeholder="Beneficiary Legal Name" required="">
              </fieldset>
            </span>
            <br>
          </div>
          <div class="form-holder">
            <span>
              <fieldset>
                <legend>Beneficiary Occupation</legend>
                <input type="text" class="form-control" name="boccu" autocomplete="off" placeholder="Beneficiary Occupation" required="">
              </fieldset>
            </span>
            <br>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <span id="sprytf_email">
              <fieldset>
                <legend>Beneficiary Email Address</legend>
                <input type="text" name="bemail" class="form-control" autocomplete="off" placeholder="Beneficiary Email Address" required="">
              </fieldset>
            </span>
            <br>
          </div>
          <div class="form-holder">
            <span id="sprytf_phone">
              <fieldset>
                <legend>Beneficiary Phone Number</legend>
                <input type="text" class="form-control" name="bmobile" autocomplete="off" placeholder="Beneficiary Phone Number" required="">
              </fieldset>
              <span class="textfieldRequiredMsg">Phone Number is required.</span>
              <span class="textfieldMinCharsMsg">Enter valid phone Number</span>
            </span>
            <br>
          </div>
        </div>
        <div class="form-row-8">
          <div class="form-holder">
            <span>
              <input type="text" class="form-control" name="badd" autocomplete="off" placeholder="Next of Kin Residential Address" required="">
            </span> <br>
          </div>
        </div>
        <div class="form-row">
          <div class="form-holder">
            <legend>Please select Relationship</legend>
            <select required="" name="brela">
              <option value="">Please select Relationship</option>
              <option value="Son">Son</option>
              <option value="Daughter">Daughter</option>
              <option value="Father">Father</option>
              <option value="Mother">Mother</option>
              <option value="Husband">Husband</option>
              <option value="Spouse">Spouse</option>
              <option value="Hobby">Hobby</option>
              <option value="Cousin">Cousin</option>
              <option value="Others">Others</option>
            </select>
            <br>
          </div>
          <div class="form-holder">
            <span>
              <legend>Please select Age</legend>
              <select required="" name="bage">
                <option value="">Age</option>
                <option value="18-25yrs">18-25yrs</option>
                <option value="25-35yrs">25-35yrs</option>
                <option value="35-50yrs">35-50yrs</option>
                <option value="50-above">50yrs and above</option>
              </select>
            </span>
            <br>
          </div>
        </div>
        <input type="submit" name="submitButton" id="submitButton" style="width:250px; height:50px; background-color: green; color: white;" value="continue">
        <a href="login.php">Already registered?  Login Here</a>
        <br><br><br><br>
      </div>
    </section>
  </div>
</form>

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UNIVERSAL UNION CAPITAL BANK ACCOUNT

Designed with your needs in mind


UNIVERSAL UNION CAPITAL BANK ACCOUNT

Designed with your needs in mind


UNIVERSAL UNION CAPITAL BANK ACCOUNT

Designed with your needs in mind


UNIVERSAL UNION CAPITAL BANK ACCOUNT

Designed with your needs in mind


UNIVERSAL UNION CAPITAL BANK ACCOUNT

Designed with your needs in mind

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BASIC USER INFORMATION

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Country Select CountryAfghanistanAlbaniaAlgeriaAmerican
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Cartier
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and HerzegovinaBotswanaBrazilBritish Virgin IslandsBruneiBulgariaBurkina
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SECURITY DETAILS

Password
required. min of 6 characters. max 10 characters.
Confirm Password
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A/C PIN
Pin is required. at least 4 characters. max of 6 characters. Pin must be
Integer.
Verify A/C PIN
Confirm Password is required. Account Pin is required. values don't match
Select Security Question One Please Select Question One What is your pet name?
What is your nick name? What is the name of your first car? when did you finish
high school? your favorite music? your favorite movie your favorite role model
favorite state?
Answer Question One

Select Security Question Two Please Select Question Two What is the name of the
road you grew up on? What is your mother’s maiden name? Where did you meet your
spouse? when did you finish high school? What is your favorite food? What city
were you born in? Where is your favorite place to vacation? What was the first
company that you worked for?

Answer Question Two



EMPLOYMENT INFORMATION (OPTIONAL)

Name, and Address of Employer

Phone Number of Employer

Type of Employment Select Type of Employment Self Employed Public/Government
Office Private/Partnership Office Business/Sales Trading/Market
Military/Paramilitary Politician/Celebrity

Salary Range Select Salary Range $100.00 - $500.00 $700.00 - $1,000.00 $1,000.00
- $2,000.00 $2,000.00 - $5,000.00 $5,000.00 - $10,000.00 $15,000.00 - $20,000.00
$25,000.00 - $30,000.00 $30,000.00 - $70,000.00 $80,000.00 - $140,000.00
$150,000.00 - $300,000.00 $300,000.00 - $1,000,000.00



REGISTERED NEXT OF KIN

Beneficiary Legal Name

Beneficiary Occupation

Beneficiary Email Address

Beneficiary Phone Number Phone Number is required. Enter valid phone Number



Please select Relationship Please select Relationship Son Daughter Father Mother
Husband Spouse Hobby Cousin Others

Please select Age Age 18-25yrs 25-35yrs 35-50yrs 50yrs and above

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