Registration

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id="firstname" name="firstname" type="text" placeholder="First name" class="form-control input-md" value=""> <span class="input-group-addon"><i class="fa fa-user"></i></span> </div> <span class="help-block" style="color:red;"></span> </div> </div>  <div class="form-group"> <label class="col-md-4 control-label" for="lastname">Last name:</label> <div class="col-md-8"> <div class="input-group"> <input id="lastname" name="lastname" type="text" placeholder="Last name" class="form-control input-md" value=""> <span class="input-group-addon"><i class="fa fa-user"></i></span> </div> <span class="help-block" style="color:red;"></span> </div> </div>  <div class="form-group"> <label class="col-md-4 control-label" for="country">Country:</label> <div class="col-md-8"> <div class="input-group"> <select class="combobox form-control" id="country" name="country"> <option>--- Select country ---</option> <option value="1" >Afghanistan</option> <option value="2" >Albania</option> <option value="3" >Algeria</option> <option value="4" >American Samoa</option> <option value="5" >Andorra</option> <option value="6" >Angola</option> <option value="7" >Anguilla</option> <option value="8" >Antarctica</option> <option value="9" >Antigua And Barbuda</option> <option value="10" >Argentina</option> <option value="11" >Armenia</option> <option value="12" >Aruba</option> <option value="13" >Australia</option> <option value="14" >Austria</option> <option value="15" >Azerbaijan</option> <option value="16" >Bahamas</option> <option value="17" >Bahrain</option> <option value="18" >Bangladesh</option> <option value="19" >Barbados</option> <option value="20" >Belarus</option> <option value="21" >Belgium</option> <option value="22" >Belize</option> <option value="23" >Benin</option> <option value="24" >Bermuda</option> <option value="25" >Bhutan</option> <option value="26" >Bolivia</option> <option value="27" >Bosnia And Herzegovina</option> <option value="28" >Botswana</option> <option value="29" >Bouvet Island</option> <option value="30" >Brazil</option> <option value="31" >British Indian Ocean Territory</option> <option value="32" >Brunei Darussalam</option> <option value="33" >Bulgaria</option> <option value="34" >Burkina Faso</option> <option value="35" >Burundi</option> <option value="36" >Cambodia</option> <option value="37" >Cameroon</option> <option value="38" >Canada</option> <option value="39" >Cape Verde</option> <option value="40" >Cayman Islands</option> <option value="41" >Central African Republic</option> <option value="42" >Chad</option> <option value="43" >Chile</option> <option value="44" >China</option> <option value="45" >Christmas Island</option> <option value="46" >Cocos (Keeling) Islands</option> <option value="47" >Colombia</option> <option value="48" >Comoros</option> <option value="49" >Congo</option> <option value="50" >Congo, The Democratic Republic Of The</option> <option value="51" >Cook Islands</option> <option value="52" >Costa Rica</option> <option value="53" >Cote D'ivoire</option> <option value="54" >Croatia</option> <option value="55" >Cuba</option> <option value="56" >Cyprus</option> <option value="57" >Czech Republic</option> <option value="58" >Denmark</option> <option value="59" >Djibouti</option> <option value="60" >Dominica</option> <option value="61" >Dominican Republic</option> <option value="62" >Ecuador</option> <option value="63" >Egypt</option> <option value="64" >El Salvador</option> <option value="65" >Equatorial Guinea</option> <option value="66" >Eritrea</option> <option value="67" >Estonia</option> <option value="68" >Ethiopia</option> <option value="69" >Falkland Islands (Malvinas)</option> <option value="70" >Faroe Islands</option> <option value="71" >Fiji</option> <option value="72" >Finland</option> <option value="73" >France</option> <option value="74" >French Guiana</option> <option value="75" >French Polynesia</option> <option value="76" >French Southern Territories</option> <option value="77" >Gabon</option> <option value="78" >Gambia</option> <option value="79" >Georgia</option> <option value="80" >Germany</option> <option value="81" >Ghana</option> <option value="82" >Gibraltar</option> <option value="83" >Greece</option> <option value="84" >Greenland</option> <option value="85" >Grenada</option> <option value="86" >Guadeloupe</option> <option value="87" >Guam</option> <option value="88" >Guatemala</option> <option value="89" >Guinea</option> <option value="90" >Guinea-Bissau</option> <option value="91" >Guyana</option> <option value="92" >Haiti</option> <option value="93" >Heard Island And Mcdonald Islands</option> <option value="94" >Holy See (Vatican City State)</option> <option value="95" >Honduras</option> <option value="96" >Hong Kong</option> <option value="97" >Hungary</option> <option value="98" >Iceland</option> <option value="99" >India</option> <option value="100" >Indonesia</option> <option value="101" >Iran, Islamic Republic Of</option> <option value="102" >Iraq</option> <option value="103" >Ireland</option> <option value="104" >Israel</option> <option value="105" >Italy</option> <option value="106" >Jamaica</option> <option value="107" >Japan</option> <option value="108" >Jordan</option> <option value="109" >Kazakhstan</option> <option value="110" >Kenya</option> <option value="111" >Kiribati</option> <option value="112" >Korea, Democratic People's Republic Of</option> <option value="113" >Korea, Republic Of</option> <option value="114" >Kuwait</option> <option value="115" >Kyrgyzstan</option> <option value="116" >Lao People's Democratic Republic</option> <option value="117" >Latvia</option> <option value="118" >Lebanon</option> <option value="119" >Lesotho</option> <option value="120" >Liberia</option> <option value="121" >Libyan Arab Jamahiriya</option> <option value="122" >Liechtenstein</option> <option value="123" >Lithuania</option> <option value="124" >Luxembourg</option> <option value="125" >Macao</option> <option value="126" >Macedonia, The Former Yugoslav Republic Of</option> <option value="127" >Madagascar</option> <option value="128" >Malawi</option> <option value="129" >Malaysia</option> <option value="130" >Maldives</option> <option value="131" >Mali</option> <option value="132" >Malta</option> <option value="133" >Marshall Islands</option> <option value="134" >Martinique</option> <option value="135" >Mauritania</option> <option value="136" >Mauritius</option> <option value="137" >Mayotte</option> <option value="138" >Mexico</option> <option value="139" >Micronesia, Federated States Of</option> <option value="140" >Moldova, Republic Of</option> <option value="141" >Monaco</option> <option value="142" >Mongolia</option> <option value="143" >Montserrat</option> <option value="144" >Morocco</option> <option value="145" >Mozambique</option> <option value="146" >Myanmar</option> <option value="147" >Namibia</option> <option value="148" >Nauru</option> <option value="149" >Nepal</option> <option value="150" >Netherlands</option> <option value="151" >Netherlands Antilles</option> <option value="152" >New Caledonia</option> <option value="153" >New Zealand</option> <option value="154" >Nicaragua</option> <option value="155" >Niger</option> <option value="156" >Nigeria</option> <option value="157" >Niue</option> <option value="158" >Norfolk Island</option> <option value="159" >Northern Mariana Islands</option> <option value="160" >Norway</option> <option value="161" >Oman</option> <option value="162" >Pakistan</option> <option value="163" >Palau</option> <option value="164" >Palestinian Territory, Occupied</option> <option value="165" >Panama</option> <option value="166" >Papua New Guinea</option> <option value="167" >Paraguay</option> <option value="168" >Peru</option> <option value="169" >Philippines</option> <option value="170" >Pitcairn</option> <option value="171" >Poland</option> <option value="172" >Portugal</option> <option value="173" >Puerto Rico</option> <option value="174" >Qatar</option> <option value="175" >Reunion</option> <option value="176" >Romania</option> <option value="177" >Russian Federation</option> <option value="178" >Rwanda</option> <option value="179" >Saint Helena</option> <option value="180" >Saint Kitts And Nevis</option> <option value="181" >Saint Lucia</option> <option value="182" >Saint Pierre And Miquelon</option> <option value="183" >Saint Vincent And The Grenadines</option> <option value="184" >Samoa</option> <option value="185" >San Marino</option> <option value="186" >Sao Tome And Principe</option> <option value="187" >Saudi Arabia</option> <option value="188" >Senegal</option> <option value="189" >Serbia</option> <option value="190" >Seychelles</option> <option value="191" >Sierra Leone</option> <option value="192" >Singapore</option> <option value="193" >Slovakia</option> <option value="194" >Slovenia</option> <option value="195" >Solomon Islands</option> <option value="196" >Somalia</option> <option value="197" >South Africa</option> <option value="198" >South Georgia And The South Sandwich Islands</option> <option value="199" >Spain</option> <option value="200" >Sri Lanka</option> <option value="201" >Sudan</option> <option value="202" >Suriname</option> <option value="203" >Svalbard And Jan Mayen</option> <option value="204" >Swaziland</option> <option value="205" >Sweden</option> <option value="206" >Switzerland</option> <option value="207" >Syrian Arab Republic</option> <option value="208" >Taiwan, Province Of China</option> <option value="209" >Tajikistan</option> <option value="210" >Tanzania, United Republic Of</option> <option value="211" >Thailand</option> <option value="212" >Timor-Leste</option> <option value="213" >Togo</option> <option value="214" >Tokelau</option> <option value="215" >Tonga</option> <option value="216" >Trinidad And Tobago</option> <option value="217" >Tunisia</option> <option value="218" >Turkey</option> <option value="219" >Turkmenistan</option> <option value="220" >Turks And Caicos Islands</option> <option value="221" >Tuvalu</option> <option value="222" >Uganda</option> <option value="223" >Ukraine</option> <option value="224" >United Arab Emirates</option> <option value="225" >United Kingdom</option> <option value="226" >United States</option> <option value="227" >United States Minor Outlying Islands</option> <option value="228" >Uruguay</option> <option value="229" >Uzbekistan</option> <option value="230" >Vanuatu</option> <option value="231" >Venezuela</option> <option value="232" >Viet Nam</option> <option value="233" >Virgin Islands, British</option> <option value="234" >Virgin Islands, U.S.</option> <option value="235" >Wallis And Futuna</option> <option value="236" >Western Sahara</option> <option value="237" >Yemen</option> <option value="238" >Zambia</option> <option value="239" >Zimbabwe</option> <option value="240" >Montenegro</option> <option value="241" > Other Country</option> </select> <span class="input-group-addon"><i class="fa fa-globe"></i></span></div> <span class="help-block" style="color:red;"></span> </div> </div> </div>  <div class="col-md-6">  <div class="form-group"> <label class="col-md-4 control-label" for="email">E-mail:</label> <div class="col-md-8"> <div class="input-group"> <input id="email" name="email" type="text" placeholder="E-mail" class="form-control input-md" value=""> <span class="input-group-addon"><i class="fa fa-envelope"></i></span> </div> <span class="help-block" style="color:red;"></span> </div> </div>  <div class="form-group"> <label class="col-md-4 control-label" for="pass">Password:</label> <div class="col-md-8"> <div class="input-group"> <input id="pass" name="pass" type="password" placeholder="Password" class="form-control input-md"> <span class="input-group-addon"><i class="fa fa-lock"></i></span> </div> <span class="help-block" style="color:red;"></span> </div> </div>  <div class="form-group"> <label class="col-md-4 control-label" for="pass2">Confirm Password:</label> <div class="col-md-8"> <div class="input-group"> <input id="pass2" name="pass2" type="password" placeholder="Confirm Password" class="form-control input-md"> <span class="input-group-addon"><i class="fa fa-lock"></i></span> </div> <span class="help-block" style="color:red;"></span> </div> </div>  <div class="form-group"> <label class="col-md-4 control-label" for="recCaptcha">Captcha:</label> <div class="col-md-8"> <div class="input-group"> <div class="g-recaptcha" data-sitekey="6Lc66BcTAAAAACGRtJ4ilI8c-N78jbjt1fHfpt9U"></div> </div> <span class="help-block" style="color:red;"></span> </div> </div> </div> </div> <div class="modal-body row"> <div class="col-md-12"> <div class="form-group"> <div class="col-md-8 col-md-offset-4"> <button id="button1id" type="submit" name="action" class="btn btn-success" value="action_save">Register</button> <button id="button2id" type="submit" name="action" class="btn btn-danger cancel" value="action_cancel">Cancel</button> </div> </div> </div> </div> </form> 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