Ain Shams Dental Journal - Journal Form for Hard Copy Order

<!DOCTYPE html>    <html>  <head> <meta charset="utf-8" /> <title>Ain Shams Dental Journal - Journal Form for Hard Copy Order</title>  <link rel="shortcut icon" type="image/ico" href="../data/asdj/coversheet/favicon.ico" />  <meta name="viewport" content="width=device-width, maximum-scale=1, initial-scale=1, user-scalable=0" />   <meta name="keywords" content="Ain Shams Dental Journal,ASDJ" /> <meta name="description" content="Ain Shams Dental Journal (ASDJ)" />  <link href="../themes/base/front/assets/css/social-icon-font.css" rel="stylesheet" type="text/css" />  <link href="../themes/base/front/assets/plugins/bootstrap/css/bootstrap.min.css?v=0.02" rel="stylesheet" type="text/css" /> <link href="../themes/old/front/assets/css/header.css?v=0.05" rel="stylesheet" type="text/css" /> <link href="../themes/old/front/assets/css/footer.css" rel="stylesheet" type="text/css" /> <link href="../inc/css/essentials.css?v=0.2" rel="stylesheet" type="text/css" /> <link 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name="subs_volume" class="form-control noradius" onchange="loadIssues()" required> <option value="0"></option> <option value="19235">Volume 1</option><option value="19236">Volume 2</option><option value="19238">Volume 4</option><option value="19237">Volume 3</option><option value="19316">Volume 5</option><option value="19317">Volume 6</option><option value="19318">Volume 7</option><option value="19319">Volume 8</option><option value="19320">Volume 9</option><option value="19321">Volume 10</option><option value="19322">Volume 11</option><option value="19323">Volume 12</option><option value="19324">Volume 13</option><option value="19325">Volume 14</option><option value="19326">Volume 15</option><option value="19327">Volume 16</option><option value="19328">Volume 17</option><option value="19329">Volume 18</option><option value="19330">Volume 19</option><option value="19331">Volume 20</option><option value="24441">Volume 21</option><option value="24442">Volume 22</option><option value="24443">Volume 23</option><option value="38293">Volume 24</option><option value="38294">Volume 25</option><option value="38295">Volume 26</option><option value="38296">Volume 27</option><option value="38297">Volume 28</option><option value="43943">Volume 29</option><option value="44222">Volume 30</option><option value="44228">Volume 31</option><option value="44691">Volume 32</option><option value="46709">Volume 33</option><option value="48076">Volume 34</option><option value="50594">Volume 35</option> </select> <i class="fancy-arrow"></i> </div> </div> <select id="sbYr" style="display: none;"> <option value="0"></option> <option value="2016">2016</option><option value="2016">2016</option><option value="2016">2016</option><option value="2016賿">2016賿</option><option value="2017">2017</option><option value="2017">2017</option><option value="2017">2017</option><option value="2017">2017</option><option value="2018">2018</option><option value="2018">2018</option><option value="2018">2018</option><option value="2018">2018</option><option value="2019">2019</option><option value="2019">2019</option><option value="2019">2019</option><option value="2019">2019</option><option value="2020">2020</option><option value="2020">2020</option><option value="2020">2020</option><option value="2020">2020</option><option value="2021">2021</option><option value="2021">2021</option><option value="2021">2021</option><option value="2021">2021</option><option value="2022">2022</option><option value="2022">2022</option><option value="2022">2022</option><option value="2022">2022</option><option value="2023">2023</option><option value="2023">2023</option><option value="2023">2023</option><option value="2023">2023</option><option value="2024">2024</option><option value="2024">2024</option><option value="2024">2024</option> </select> <div class="col-md-4" > <label for="subs_volume">Issue</label> <div class="fancy-form fancy-form-select"> <select id="subs_issue" name="subs_issue" class="form-control noradius" required> <option value="0"></option> </select> <i class="fancy-arrow"></i> </div> </div> <div class="col-md-4" > <label for="subs_volume">Publish Year</label> <div class="fancy-form fancy-form-select"> <select id="subs_year" name="subs_year" class="form-control noradius" required> <option value="0"></option> <option value="2016">2016</option><option value="2016賿">2016賿</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> </select> <i class="fancy-arrow"></i> </div> </div> </div> <div class="row" > <div class="col-md-6" > <label for="subs_volume">Subscription Type</label> <div class="fancy-form fancy-form-select"> <select id="subs_type" name="subs_type" class="form-control noradius" required> <option value="0"></option> <option value=""></option><option value="Institutional">Institutional</option><option value="Personal">Personal</option><option value="Student">Student</option><option value="Single Copy">Single Copy</option> </select> <i class="fancy-arrow"></i> </div> </div> <div class="col-md-6" > <div class="form-group"> <label >Number of Copies</label> <input class="form-control noradius" type="text" id="subs_count" name="subs_count" value="1" required > </div> </div> </div> <div class="row" > <div class="col-sm-12"> <div class="form-group">  <label>Postal Address</label> <textarea type="text" id="post_address" name="post_address" class="form-control radius-0" rows="6" required></textarea>  </div> </div> </div> <div class="row" > <div class="col-sm-12"> <div class="form-group"> <label>Bank Receipt </label> <div class="fancy-file-upload fancy-file-default"> <i class="fa fa-upload"></i> <input class="form-control" id="payment_receipt" name="payment_receipt" onchange="jQuery(this).next('input').val(this.value);" type="file" > <input class="form-control" readonly="" type="text" required> <span class="button" style="margin: 0;height: auto;cursor: pointer;" onclick="jQuery(this).siblings('input[type=file]').click();">Choose File</span> </div> </div> </div> </div> <div class="row" > <div class="col-xs-12"> <div class="form-group" style="padding-top: 25px;"> <button type="submit" type="submit" name="subscribe" class="pull-right btn btn-3d btn-md btn-reveal btn-primary nomargin"> <i class="fa fa-check"></i> <span>Send Request</span> </button> </div> </div> </div> </form> <script type="text/javascript"> document.addEventListener("DOMContentLoaded", function(event) { loadIssues(); shPaymentInfo(); }); </script> </div> </section> </div> </div>   <section class="alternate padding-xxs"> </section>   <div class="container"> <footer id="footer"> <div class="scrollup" id="scroll" href="#"><span></span></div> <div class="row"> <div class="col-md-2">  <h4 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Ain Shams Dental Journal - Journal Form for Hard Copy Order