asia.venum.com
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172.67.21.8
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Submitted URL: http://asia.venum.com/
Effective URL: https://asia.venum.com/
Submission: On June 09 via manual from US — Scanned from CA
Effective URL: https://asia.venum.com/
Submission: On June 09 via manual from US — Scanned from CA
Form analysis
6 forms found in the DOMGET https://asia.venum.com/catalogsearch/result/
<form class="form minisearch" id="search_mini_form" action="https://asia.venum.com/catalogsearch/result/" method="get">
<div class="field search"><label class="label" for="search" data-role="minisearch-label"><span>Search</span></label>
<div class="control"><input id="search" type="text" name="q" value="" placeholder="Search" class="input-text" maxlength="128" aria-haspopup="false" aria-autocomplete="both" autocomplete="off" data-block="autocomplete-form">
<div class="mobile-search-loading"><img src="https://asia.venum.com/static/version1654148998/frontend/Venum/newvenum/en_US/images/loader-1.gif" title="dragonbleu elastic search" alt="search"></div>
</div>
</div>
<div class="actions"><button type="submit" title="Search" class="action search" disabled=""><span>Search</span>
<div class="no-mobile-search-loading"><img src="https://asia.venum.com/static/version1654148998/frontend/Venum/newvenum/en_US/images/loader-1.gif" title="dragonbleu elastic search" alt="search"></div>
</button></div>
</form>
POST https://asia.venum.com/newsletter/subscriber/new
<form class="form subscribe" novalidate="novalidate" method="post" action="https://asia.venum.com/newsletter/subscriber/new">
<div class="field newsletter"><label class="label" for="newsletter-543"><span>Sign Up for Our Newsletter:</span></label>
<div class="control"><input name="email" type="email" id="newsletter-543" placeholder="Your address email" data-validate="{required:true, 'validate-email':true}"></div>
</div>
<div class="actions"><button class="action subscribe primary" title="Subscribe" type="submit"><span>Subscribe</span></button></div>
</form>
<form class="needsclick klaviyo-form klaviyo-form-version-cid_1 kl-private-reset-css-Xuajs1" data-testid="klaviyo-form-U4Mh2Z" novalidate="" tabindex="-1"
style="display: flex; flex-direction: row; box-sizing: border-box; overflow: hidden; width: 780px; min-width: 200px; max-width: 1000px; border-radius: 4px; border-style: none; border-width: 0px; border-color: rgb(0, 0, 0); background-color: rgb(255, 255, 255); background-image: url("https://d3k81ch9hvuctc.cloudfront.net/company/TnxWRA/images/d4bea5b0-d856-4f36-8b31-7a0521633828.png"); background-repeat: no-repeat; background-size: cover; background-position: 50% 50%; padding: 20px 15px;">
<div class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: column; width: 100%; margin: 0px; padding: 0px; min-height: 500px; justify-content: center;">
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; flex: 1 0 0px;">
<div class="kl-private-reset-css-Xuajs1 kl-private-quill-wrapper-Lkqws1" style="width: 100%;">
<div class="ql-snow ql-container ql-disabled">
<div class="ql-editor" data-gramm="false" contenteditable="false">
<p style="text-align: center;"><span style="color: rgb(255, 255, 255);">JOIN THE VENUM TEAM</span></p>
</div>
<div class="ql-clipboard" contenteditable="true" tabindex="-1"></div>
</div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; flex: 1 0 0px;">
<div class="kl-private-reset-css-Xuajs1 kl-private-quill-wrapper-Lkqws1" style="width: 100%;">
<div class="ql-snow ql-container ql-disabled">
<div class="ql-editor" data-gramm="false" contenteditable="false">
<p><br></p>
<p><br></p>
<p><br></p>
</div>
<div class="ql-clipboard" contenteditable="true" tabindex="-1"></div>
</div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px 0px 0px; position: relative; flex: 1 0 0px;">
<div class="kl-private-reset-css-Xuajs1 kl-private-quill-wrapper-Lkqws1" style="width: 100%;">
<div class="ql-snow ql-container ql-disabled">
<div class="ql-editor" data-gramm="false" contenteditable="false">
<p style="text-align: center;"><strong style="font-size: 48px; color: rgb(255, 255, 255);" class="ql-font-arial-black">GET 10% OFF*</strong></p>
</div>
<div class="ql-clipboard" contenteditable="true" tabindex="-1"></div>
</div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; flex: 1 0 0px;">
<div class="kl-private-reset-css-Xuajs1 kl-private-quill-wrapper-Lkqws1" style="width: 100%;">
<div class="ql-snow ql-container ql-disabled">
<div class="ql-editor" data-gramm="false" contenteditable="false">
<p style="text-align: center;"><span style="font-size: 16px; color: rgb(255, 255, 255);" class="ql-font-poppins">SUBSCRIBE TO OUR NEWSLETTER AND GET 10% OFF YOUR NEXT ORDER</span></p>
</div>
<div class="ql-clipboard" contenteditable="true" tabindex="-1"></div>
</div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px 0px; position: relative; flex: 1 0 0px;">
<div class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-grow: 1; flex-direction: column; align-self: flex-end;"><input class="needsclick go2142240638 kl-private-reset-css-Xuajs1" type="email" name="email" tabindex="0"
placeholder="Email address" aria-label="Email address" aria-invalid="false" options="[object Object]"
style="box-sizing: border-box; border-radius: 4px; padding: 0px 0px 0px 16px; height: 50px; text-align: left; color: rgb(0, 0, 0); font-family: Poppins, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; font-weight: 700; letter-spacing: 0px; background-color: rgb(255, 255, 255); border: 1px solid rgb(96, 106, 114);">
<div class="needsclick kl-private-reset-css-Xuajs1" style="width: 100%; position: relative;"></div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; flex: 1 0 0px;">
<div class="kl-private-reset-css-Xuajs1 kl-private-quill-wrapper-Lkqws1" style="width: 100%;">
<div class="ql-snow ql-container ql-disabled">
<div class="ql-editor" data-gramm="false" contenteditable="false">
<p><span style="color: rgb(255, 255, 255);">YOUR FAVORITE SPORT</span></p>
</div>
<div class="ql-clipboard" contenteditable="true" tabindex="-1"></div>
</div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; flex: 1 0 0px;">
<div class="needsclick kl-private-reset-css-Xuajs1" style="width: 100%; align-self: flex-end;">
<div class="needsclick kl-private-reset-css-Xuajs1">
<div role="combobox" aria-haspopup="listbox" aria-owns="downshift-0-menu" aria-expanded="false" class="needsclick kl-private-reset-css-Xuajs1" style="position: relative; display: flex;"><button
class="needsclick go324349249 kl-private-reset-css-Xuajs1" id="downshift-0-toggle-button" tabindex="0" type="button" aria-label="What is your favorite sport"
style="flex: 1 1 0%; display: flex; flex-direction: row; align-items: center; justify-content: space-between; box-sizing: border-box; background-color: rgb(255, 255, 255); padding: 0px 8px 0px 16px; border: 1px solid rgb(96, 106, 114); height: 50px; cursor: pointer; border-radius: 4px;"><input
class="needsclick go2679248356 kl-private-reset-css-Xuajs1" readonly="" tabindex="-1" placeholder="What is your favorite sport" id="downshift-0-input" aria-autocomplete="list" aria-controls="downshift-0-menu"
aria-labelledby="downshift-0-label" autocomplete="off"
style="border: none; flex: 1 1 0%; cursor: pointer; color: rgb(0, 0, 0); font-family: Poppins, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; font-weight: 700; letter-spacing: 0px;"><svg height="20"
width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="" transform="" tabindex="-1" style="fill: rgb(96, 106, 114);">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></button>
<div id="downshift-0-menu" role="listbox" aria-labelledby="downshift-0-label" class="needsclick kl-private-reset-css-Xuajs1"
style="background-color: rgb(255, 255, 255); box-sizing: border-box; width: 100%; max-height: 150px; position: absolute; overflow-y: auto; z-index: 1; border: none; top: 100%; border-bottom-right-radius: 4px; border-bottom-left-radius: 4px;">
</div>
</div>
</div>
<div class="needsclick kl-private-reset-css-Xuajs1" style="width: 100%; position: relative;"></div>
</div>
</div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1"
style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; background-color: rgba(255, 255, 255, 0); flex: 1 0 0px;"><button class="needsclick go952291206 kl-private-reset-css-Xuajs1" type="button" tabindex="0"
style="background: rgb(33, 29, 28); border-radius: 6px; border-style: none; border-color: rgb(33, 29, 28); border-width: 3px; color: rgb(255, 255, 255); font-family: Poppins, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 18px; font-weight: 700; letter-spacing: 0px; line-height: 1; white-space: normal; padding-top: 0px; padding-bottom: 0px; text-align: center; word-break: break-word; align-self: flex-end; cursor: pointer; height: 54px; width: 100%;">JOIN
THE TEAM ! </button></div>
</div>
<div data-testid="form-row" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; flex-direction: row; align-items: stretch; position: relative;">
<div component="[object Object]" data-testid="form-component" class="needsclick kl-private-reset-css-Xuajs1" style="display: flex; justify-content: flex-start; padding: 10px 6px; position: relative; flex: 1 0 0px;">
<div class="kl-private-reset-css-Xuajs1 kl-private-quill-wrapper-Lkqws1" style="width: 100%;">
<div class="ql-snow ql-container ql-disabled">
<div class="ql-editor" data-gramm="false" contenteditable="false">
<p><span style="font-size: 9px; color: rgb(255, 255, 255);">By clicking on "Join the team!", you have read and accepted VENUM's general Sales Agreement and confirmed your subscription to the VENUM newsletter</span></p>
<p><span style="font-size: 9px; color: rgb(255, 255, 255);">*discount applicable to the entire site except the discounted products, UFC I VENUM collection, new products and bulky goods (punching bag, etc), for a limited term.</span></p>
</div>
<div class="ql-clipboard" contenteditable="true" tabindex="-1"></div>
</div>
</div>
</div>
</div>
</div><input type="submit" tabindex="-1" value="Submit" style="display: none;">
</form>
POST
<form class="form form-login" method="post" data-bind="event: {submit: login }" id="login-form">
<div class="fieldset login" data-bind="attr: {'data-hasrequired': $t('* Required Fields')}" data-hasrequired="* Required Fields">
<div class="field email required">
<label class="label" for="customer-email"><span data-bind="i18n: 'Email Address'">Email Address</span></label>
<div class="control">
<input name="username" id="customer-email" type="email" class="input-text" data-mage-init="{"mage/trim-input":{}}" data-bind="attr: {autocomplete: autocomplete}" data-validate="{required:true, 'validate-email':true}"
autocomplete="off">
</div>
</div>
<div class="field password required">
<label for="pass" class="label"><span data-bind="i18n: 'Password'">Password</span></label>
<div class="control">
<input name="password" type="password" class="input-text" id="pass" data-bind="attr: {autocomplete: autocomplete}" data-validate="{required:true}" autocomplete="off">
</div>
</div>
<!-- ko foreach: getRegion('additional-login-form-fields') -->
<!-- ko template: getTemplate() -->
<input name="captcha_form_id" type="hidden" data-bind="value: formId, attr: {'data-scope': dataScope}" value="user_login" data-scope="">
<!-- ko if: (isRequired() && getIsVisible())--><!-- /ko -->
<!-- /ko -->
<!-- /ko -->
<div class="actions-toolbar">
<input name="context" type="hidden" value="checkout">
<div class="primary">
<button type="submit" class="action action-login secondary" name="send" id="send2">
<span data-bind="i18n: 'Sign In'">Sign In</span>
</button>
</div>
<div class="secondary">
<a class="action" data-bind="attr: {href: forgotPasswordUrl}" href="https://asia.venum.com/customer/account/forgotpassword/">
<span data-bind="i18n: 'Forgot Your Password?'">Forgot Your Password?</span>
</a>
</div>
</div>
</div>
</form>
POST
<form class="form form-login" method="post" data-bind="event: {submit: login }" id="ajaxlogin-form">
<div class="fieldset login" data-bind="attr: {'data-hasrequired': $t('* Required Fields')}" data-hasrequired="* Required Fields">
<div class="field email required">
<div class="control">
<input name="username" id="ajaxlogin-email" type="email" class="input-text" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('Email Address')} " data-validate="{required:true, 'validate-email':true}" autocomplete="off"
placeholder="Email Address">
</div>
</div>
<div class="field password required">
<div class="control">
<input name="password" type="password" class="input-text" id="ajaxlogin-pass" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('Password')}" data-validate="{required:true}" autocomplete="off" placeholder="Password">
</div>
</div>
<!-- ko foreach: getRegion('additional-login-form-fields') --><!-- /ko -->
<div class="actions-toolbar">
<div class="secondary">
<a class="action" data-bind="attr: {href: forgotPasswordUrl}" href="https://asia.venum.com/customer/account/forgotpassword/">
<span data-bind="i18n: 'Forgot Your Password?'">Forgot Your Password?</span>
</a>
</div>
<div class="third">
<div data-bind="i18n: 'By logging in, you agree to abide by Venum\'s '">By logging in, you agree to abide by Venum's </div>
<a href="/en/privacy-policy">
<span data-bind="i18n: 'Privacy Policy'">Privacy Policy</span>
</a>
<span data-bind="i18n: 'and'">and</span>
<a href="/en/sales-agreements">
<span data-bind="i18n: 'Terms and Conditions'">Terms and Conditions</span>
</a>
<span data-bind="i18n: ''"></span>
</div>
<div class="primary">
<button type="submit" class="action action-login secondary" name="send" id="ajaxlogin-send">
<span data-bind="i18n: 'Sign In'">Sign In</span>
</button>
</div>
</div>
</div>
</form>
POST
<form class="form form-register" method="post" id="ajaxregisterform" data-mage-init="{"validation":{}}" data-bind="event: {submit: register }" autocomplete="off">
<div class="fieldset register" data-bind="attr: {'data-hasrequired': $t('* Required Fields')}" data-hasrequired="* Required Fields">
<div class="field email required">
<div class="control">
<input name="email" id="email" type="email" class="input-text" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('Email Address')} " data-validate="{required:true, 'validate-email':true}" autocomplete="off"
placeholder="Email Address">
</div>
</div>
<div class="field password required">
<div class="control">
<input name="password" type="password" class="input-text" id="password" data-password-min-length="8" data-password-min-character-sets="1" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('Password')}"
data-validate="{required:true }" autocomplete="off" placeholder="Password">
</div>
</div>
<div class="field confirmation required">
<div class="control">
<input name="password_confirmation" type="password" class="input-text" id="password-confirmation" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('Confirm Password *')}" data-validate="{ required:true}" autocomplete="off"
placeholder="Confirm Password *">
</div>
</div>
<div class="field name-firstname required">
<div class="control">
<input name="firstname" type="text" class="input-text" id="ajaxregister-firstname" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('First Name *')}" data-validate="{required:true}" autocomplete="off" placeholder="First Name *">
</div>
</div>
<div class="field name-lastname required">
<div class="control">
<input name="lastname" type="text" class="input-text" id="ajaxregister-lastname" data-bind="attr: {autocomplete: autocomplete ,placeholder: $t('Last Name *')}" data-validate="{required:true}" autocomplete="off" placeholder="Last Name *">
</div>
</div>
<div class="field date field-dob">
<div class="control customer-dob">
<input type="text" name="dob" value="" id="ajaxregister-dob" class="_has-datepicker" data-validate="{required:true}" title=" Your Date of Birth" autocomplete="off" data-bind="attr: {placeholder: $t('Date of Birth')}"
onfocus="(this.type='date')" onblur="(this.type='text')" placeholder="Date of Birth">
</div>
</div>
<div class="field filed-gender required">
<input type="radio" value="1" name="gender" id="male" checked=""><label for="male" data-bind="i18n: 'Male'">Male</label>
<input type="radio" value="2" name="gender" id="female"><label for="female" data-bind="i18n: 'Female'">Female</label>
</div>
<div class="field country required">
<div class="control">
<select name="country_id" id="ajaxregister-country" class="" title="Country" data-validate="{'validate-select':true}" aria-required="true">
<option value=""> </option>
<option value="AL">Albanie</option>
<option value="DZ">Algérie</option>
<option value="DE">Allemagne</option>
<option value="AD">Andorre</option>
<option value="AT">Autriche</option>
<option value="BE">Belgique</option>
<option value="BA">Bosnie-Herzégovine</option>
<option value="BG">Bulgarie</option>
<option value="CY">Chypre</option>
<option value="HR">Croatie</option>
<option value="DK">Danemark</option>
<option value="ES">Espagne</option>
<option value="EE">Estonie</option>
<option value="FI">Finlande</option>
<option value="FR" selected="selected">France</option>
<option value="GI">Gibraltar</option>
<option value="GL">Groenland</option>
<option value="GR">Grèce</option>
<option value="GP">Guadeloupe</option>
<option value="GG">Guernesey</option>
<option value="GY">Guyana</option>
<option value="GF">Guyane française</option>
<option value="GE">Géorgie</option>
<option value="HU">Hongrie</option>
<option value="IE">Irlande</option>
<option value="IT">Italie</option>
<option value="JE">Jersey</option>
<option value="RE">La Réunion</option>
<option value="LV">Lettonie</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lituanie</option>
<option value="LU">Luxembourg</option>
<option value="MK">Macédoine</option>
<option value="MT">Malte</option>
<option value="MA">Maroc</option>
<option value="MQ">Martinique</option>
<option value="MD">Moldavie</option>
<option value="MC">Monaco</option>
<option value="ME">Monténégro</option>
<option value="NO">Norvège</option>
<option value="NZ">Nouvelle-Zélande</option>
<option value="NL">Pays-Bas</option>
<option value="PL">Pologne</option>
<option value="PF">Polynésie française</option>
<option value="PT">Portugal</option>
<option value="RO">Roumanie</option>
<option value="GB">Royaume-Uni</option>
<option value="SM">Saint-Marin</option>
<option value="RS">Serbie</option>
<option value="SK">Slovaquie</option>
<option value="SI">Slovénie</option>
<option value="CH">Suisse</option>
<option value="SE">Suède</option>
<option value="CZ">Tchéquie</option>
<option value="TN">Tunisie</option>
<option value="TR">Turquie</option>
<option value="EG">Égypte</option>
<option value="VA">État de la Cité du Vatican</option>
<option value="FO">Îles Féroé</option>
<option value="AX">Îles Åland</option>
</select>
</div>
</div>
<div class="discipline-container">
<div class="field field-discipline">
<div class="control">
<select multiple="multiple" id="discipline" name="discipline[]">
<option value="" selected="selected"> </option>
<option value="1447">boxe</option>
<option value="1448">muay thai</option>
<option value="1449">mma</option>
<option value="1450">karaté</option>
<option value="1451">judo</option>
<option value="1452">aikido & kendo</option>
<option value="1453">jiu-jitsu brésilien</option>
<option value="1454">crossfit & cross training</option>
<option value="1455">fitness & yoga</option>
<option value="1456">taekwondo</option>
<option value="1457">krav-maga & self-defense</option>
<option value="1458">autres</option>
</select>
</div>
</div>
</div>
<div class="field choice newsletter">
<input type="checkbox" name="is_subscribed" title="Sign Up for Newsletter" value="1" id="is_subscribed" class="checkbox">
<label for="is_subscribed" class="label"><span data-bind="i18n:'Sign up to receive the latest information on Venum products and special offers by email'">Sign up to receive the latest information on Venum products and special offers by
email</span></label>
</div>
<div class="label-legal">
<div data-bind="i18n: 'By logging in, you agree to abide by Venum\'s '">By logging in, you agree to abide by Venum's </div>
<a href="/en/privacy-policy">
<span data-bind="i18n: 'Privacy Policy'">Privacy Policy</span>
</a>
<span data-bind="i18n: 'and'">and</span>
<a href="/en/sales-agreements">
<span data-bind="i18n: 'Terms and Conditions'">Terms and Conditions</span>
</a>
<span data-bind="i18n: ' '"> </span>
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<!-- ko foreach: getRegion('additional-register-form-fields') --><!-- /ko -->
<fieldset class="fieldset address" style="display: none">
<input type="hidden" name="create_address" value="1">
<div class="field company">
<label for="company" class="label"><span>Company</span></label>
<div class="control">
<input type="text" name="company" id="company" value="" title="Company" class="input-text " autocomplete="off">
</div>
</div>
<div class="field telephone required">
<label for="telephone" class="label"><span>Phone Number</span></label>
<div class="control">
<input value="" type="text" name="telephone" id="telephone" title="Phone Number" class="input-text required-entry" autocomplete="off" aria-required="true">
</div>
</div>
<div class="field street required">
<label for="street_1" class="label"><span>Street Address</span></label>
<div class="control">
<input type="text" name="street" value="" title="Street Address" id="street_1" class="input-text required-entry" autocomplete="off" aria-required="true">
</div>
</div>
<div class="field required">
<label for="city" class="label"><span>City</span></label>
<div class="control">
<input type="text" name="city" value="-" title="City" class="input-text required-entry" id="city" autocomplete="off" aria-required="true">
</div>
</div>
<div class="field region required">
<label for="region_id" class="label"><span>State/Province</span></label>
<div class="control">
<select id="region_id" name="region_id" title="State/Province" class="validate-select" style="display:none;" aria-required="true">
<option value="">Please select a region, state or province.</option>
</select>
<input type="text" id="region" name="region" value="" title="State/Province" class="input-text " style="display:none;" autocomplete="off" aria-required="true">
</div>
</div>
<div class="field zip">
<label for="zip" class="label"><span>Zip/Postal Code</span></label>
<div class="control">
<input type="text" name="postcode" value="" title="Zip/Postal Code" id="zip" class="input-text validate-zip-international " data-validate="{'required':true, 'validate-zip-international':true}" autocomplete="off">
</div>
</div>
<input type="hidden" name="vat_id" value="null">
<input type="hidden" name="default_billing" value="1">
<input type="hidden" name="default_shipping" value="1">
</fieldset>
<div class="actions-toolbar">
<div class="primary">
<button type="submit" value="submit" class="action action-register secondary" name="send" id="ajaxregister-send">
<span data-bind="i18n: 'Create an Account'">Create an Account</span>
</button>
</div>
</div>
</div>
</form>
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