<?php 
$INC_DIR = $_SERVER['DOCUMENT_ROOT']."/v1/app/";
include $INC_DIR."src/common.php";

$customer_details=get_customer_details($configs);
?>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<title><?php echo $configs->page_title; ?></title>
<meta content="width=device-width, initial-scale=1" name="viewport">
<link href="../assets/brand/favicon.png" rel="icon" type="image/png">

<link href="../assets/css/app.css" rel="stylesheet">
<link href="assets/css/inner.css" type="text/css" rel="stylesheet">
<link rel="preconnect" href="https://fonts.gstatic.com">
<link href="https://fonts.googleapis.com/css2?family=Open+Sans:wght@400;700&family=Oswald:wght@400;500;600;700&family=Roboto+Condensed:ital,wght@0,400;0,700;1,400;1,700&display=swap" rel="stylesheet">
<link href="../assets/css/jquery.autocomplete.css" rel="stylesheet">
<script>
	history.pushState(null, null, window.location.href);
	history.back();
	history.forward(); 
	window.onpopstate = function () { history.go(1); };
</script>
<style>
	.has-error{
		border: 2px solid #ff5e45 !important;
		background-image: url('./assets/images/icon-validation-bad.png') !important;
		background-position: right center !important;
		background-repeat: no-repeat !important;
		background-size: 30px !important;
	}
	.no-error{
		border: 2px solid #6abd6a !important;
		background-image: url('./assets/images/icon-validation-good.png') !important;
		background-position: right center !important;
		background-repeat: no-repeat !important;
		background-size: 30px !important;
	}
</style>
</head>

<body data-mobile-id="5984" style="max-width: 600px; margin: 0 auto">
<div id="app">
    <div id="pagecontainer">
        <div id="top-1">
            <center>
                <img src="assets/brand/logo2-strips.png" style="width:158px; margin: 6px 0 10px 0;">
            </center>

            <div class="breadcrumbs">
                <ul class="breadcrumbs__list">
                    <li class="breadcrumbs__item breadcrumbs__item_active">
                        <span>Qualify Now</span>
                    </li>
                    <li class="breadcrumbs__item breadcrumbs__item_2">
                        <span>Select Package</span>
                    </li>
                    <li class="breadcrumbs__item breadcrumbs__item_3">
                        <span>Confirm Order</span>
                    </li>
                </ul>
            </div>

            <p style="text-align:center;">
                <br>
                <b style="color:#f18704; font-size:19px; padding: 0 5px">Claim Your KETO Package Today!</b><br>
                <br>
                <strong style="padding: 0 5px">At 10x the Fat Burn,<br>You Won't Believe it's All Natural!</strong>
                <br>
            </p>
            </div>

            <div class="form-partial" style="max-width:95%; margin:0 auto;">

               <form name="qualify_form1" class="kform form123" id="theForm" method="POST" action="/v1/app/src/ajax.php" onsubmit="return validate_optin_form()" accept-charset="utf-8" enctype="application/x-www-form-urlencoded;charset=utf-8" _lpchecked="1">
								 
					<input type="hidden" name="device" value="mobile">
					<input type="hidden" name="pgtag" value="mqualify">
					<input type="hidden" name="shippingCountry" id="shippingCountry" value="US">
					<?php
						foreach($customer_details['affiliate_details'] as $key => $value) {
							echo "<input type='hidden' name='".$key."' value='".$value."'>";
						}
					?>
				            
                    <div class="lead-form-wrapper">
                        <div class=" columns form-holder">
                            <label>First Name:</label>
                            <input class="form-control required" data-placement="auto left" name="firstName" id='fields_fname' placeholder="First Name*" title="First Name*" type="text" value="" autocomplete="given-name" onKeyUp="javascript: this.value = this.value.replace(/[^a-zA-Z]/g, '');">
                        </div>
                        <div class=" columns form-holder">
                            <label>Last Name:</label>
                            <input class="form-control required" data-placement="auto left" name="lastName" id='fields_lname' placeholder="Last Name*" title="Last Name*" type="text" value="" autocomplete="family-name" onKeyUp="javascript: this.value = this.value.replace(/[^a-zA-Z]/g, '');">
                        </div>
                        <div class=" columns">
                            <label>Email:</label>
                            <input class="form-control required" data-placement="auto left" name="email" id='fields_email' placeholder="Email*" title="Email" type="email" value="" autocomplete="email">
                        </div>
                        <div class=" columns">
                            <label>Phone:</label>
                            <input class="form-control required" data-placement="auto left" name="phone" id="fields_phone" placeholder="Phone Number*"  title="Phone Number" type="tel" value="" maxlength="10" autocomplete="tel-national">
                        </div>
                        <span style="font-size: 14px;">How Much Weight Would You Like To Lose?</span>
                        <div class="form-holder">
                            <select name="fields_want" id='fields_want' class="required">
                                <option selected="selected" value="0">Please Select</option>
                                <option value="1">1-10 lbs</option>
                                <option value="11">11-20 lbs</option>
                                <option value="20">20 plus lbs</option>
                            </select>
                        </div>
                        <br>
                        <input alt="Submit" border="0" class="pulsebutton btn_pulse qualify-btn" name="partialsubmitbutton" src="assets/images/qualify-btn.jpg" style="width: 100%; outline:none;" type="image" value="submit">
                    </div>
                </form>
            </div>
        </div>
    </div>

    <div class="linebreak" style="margin:15px 0;">
    </div>

    <div>
        <img alt="" src="assets/images/godaddyimg.png">
    </div>

    <div class="linebreak" style="margin:15px 0;">
    </div>

    <div>
        <img alt="" src="assets/images/safe.png">
    </div>

    <div class="linebreak" style="margin:15px 0;">
    </div>

    <div id="footer">
        <br>
        <center>
            <ul class="terms-links">
                <li> <a href="javascript:void(0);" onClick="openNewWindow('../disclosures/privacy.php','modal');">Privacy Policy |</a></li>
                <li> <a href="javascript:void(0);" onClick="openNewWindow('../disclosures/terms.php','modal');">Terms and Conditions |</a></li>
                <li><a href="javascript:void(0);" onClick="openNewWindow('../disclosures/wireless.php','modal');">Wireless Policy</a></li>
								
            </ul>
            <br>
            <div class="text-center">
                <p><?php echo $configs->step_1_name; ?> is committed to maintaining the highest quality products and the utmost integrity in business practices. All products sold on this website are certified by Good Manufacturing Practices (GMP), which is the highest standard of testing in the supplement industry.</p><br><p>Notice: The products and information found on this site are not intended to replace professional medical advice or treatment. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. Individual results may vary.</p>
            </div>
            <br>
        </center>

        <center>
            <div class="text-center">
                <p class="cop-text">&copy; <script> var date = new Date(); document.write(date.getFullYear()) </script> <span class="product-name"><?php echo $configs->step_1_name; ?></span>. All Rights Reserved.</p>
                <br>
            </div>
        </center>
        <p></p>
    </div>
</div>

<p id="loading-indicator" style="display:none;">Processing...</p>
<p id="crm-response-container" style="display:none;">Limelight messages will appear here...</p>

<script type="text/javascript" src="assets/js/jquery-3.5.1.min.js"></script> 
<script type="text/javascript" src="../assets/js/jquery.autocomplete.min.js"></script>
<script type="text/javascript" src="assets/js/jquery.mask.min.js"></script>	
<script type="text/javascript" src="assets/js/custom.js"></script>
</body>
</html>