CINXE.COM
BioSpectrum Asia
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <title>BioSpectrum Asia </title> <link href="css/style.css" rel="stylesheet" type="text/css" /> <script type="text/javascript" src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script> <script language="javascript" type="text/javascript"> function check_num(e,txt) { var unicode=e.keyCode? e.keyCode : e.charCode; var text1 = txt; if((unicode == "48") || (unicode == "49") || (unicode == "50") || (unicode == "51") || (unicode=="52") || (unicode=="53") || (unicode=="54") || (unicode=="55") || (unicode=="56") || (unicode=="57") || (unicode=="96") || (unicode=="97") || (unicode=="98") || (unicode=="99") || (unicode=="100") || (unicode=="101") || (unicode=="102") || (unicode=="103") || (unicode=="104") || (unicode=="105") || 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alert("Please Enter Lastname."); document.getElementById("lastname").focus(); return false; } if(document.getElementById("job_title").value == "") { alert("Please Enter Job Title."); document.getElementById("job_title").focus(); return false; } if(document.getElementById("subscrtion_plan").value == "" && document.getElementById("flipbook_plan").value == "") { alert("Please select: Are you from(Subscription plan) or Subscribe to Flipbook or both plan"); document.getElementById("are_you_from").focus(); return false; } if(document.getElementById("are_you_from").value != "") { if(document.getElementById("subscrtion_plan").value == "") { alert("Please select Subscription plan"); document.getElementById("subscrtion_plan").focus(); return false; } } if(document.getElementById("company").value == "") { alert("Please Enter Company."); document.getElementById("company").focus(); return false; } if(document.getElementById("address_type").value == "") { alert("Please Select Address Type"); document.getElementById("address_type").focus(); return false; } if(document.getElementById("addr").value == "") { alert("Please Enter Address."); document.getElementById("addr").focus(); return false; } if(document.getElementById("city").value == "") { alert("Please Enter City."); document.getElementById("city").focus(); return false; } if(document.getElementById("state").value == "") { alert("Please Enter State."); document.getElementById("state").focus(); return false; } if(document.getElementById("country").value == "") { alert("Please Select Country."); document.getElementById("country").focus(); return false; } if(document.getElementById("pincode").value == "") { alert("Please Enter Pincode."); document.getElementById("pincode").focus(); return false; } if(document.getElementById("telephone").value == "") { alert("Please Enter Telephone."); document.getElementById("telephone").focus(); return false; } if(document.getElementById("mob").value == "") { alert("Please Enter Mobile."); document.getElementById("mob").focus(); return false; } if(document.getElementById("email").value == "") { alert("Please Enter Email-Id."); document.getElementById("email").focus(); return false; } else if(document.getElementById("email").value != "") { var reg = /^([a-zA-Z0-9_\.\-])+\@(([a-zA-Z0-9\-])+\.)+([a-zA-Z0-9]{2,4})+$/; var toArr= document.getElementById("email").value.split(","); //split into array for (var i=0;i<toArr.length;i++) //loop array to validate correct address { if ( !toArr[i].match(reg) ) //if not match, alert and stop loop { alert("Invalid email address \n"+toArr[i]); document.getElementById("email").focus(); return false; } } } if(document.getElementById("paymode1").checked == false && document.getElementById("paymode2").checked == false) { alert("Please select Payment Mode."); document.getElementById("paymode1").focus(); return false; } if(document.getElementById("vercode").value == "") { alert("Please fill the characters you see in image."); document.getElementById("vercode").focus(); return false; } else if(document.getElementById("vercode").value != "") { compstr = document.getElementById("test").value; if(document.getElementById("vercode").value != compstr) { alert("Please fill correct characters you see in image."); document.getElementById("vercode").value = ""; document.getElementById("vercode").focus(); return false; } } return true; } function showPayment() { if(document.getElementById("paymode1").checked == true) { document.getElementById("bt").style.display = "block"; } else if(document.getElementById("paymode2").checked == true) { document.getElementById("bt").style.display = "none"; } } function showPlan() { $('.other_plan').hide(); $('.sing_plan').hide(); $('#sub-plan').hide(); var are_you_from = $('#are_you_from').val();//alert(are_you_from); if(are_you_from != '') { $('#sub-plan').show(); } if(are_you_from == "Singapore") { $('.sing_plan').show(); $('.other_plan').hide(); } if(are_you_from == "Other than Singapore") { $('.other_plan').show(); $('.sing_plan').hide(); } $('#subscrtion_plan').val(''); } $(document).ready(function() { showPlan(); }); </script> <script> (function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){ (i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o), m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m) })(window,document,'script','https://www.google-analytics.com/analytics.js','ga'); ga('create', 'UA-58743002-1', 'auto'); ga('send', 'pageview'); </script> <style type="text/css"> .effect7 { position:relative; -webkit-box-shadow:0 1px 4px rgba(0, 0, 0, 0.3), 0 0 40px rgba(255, 0, 0, 0.4) inset; -moz-box-shadow:0 1px 4px rgba(0, 0, 0, 0.3), 0 0 40px rgba(255, 0, 0, 0.4) inset; box-shadow:0 1px 4px rgba(0, 0, 0, 0.3), 0 0 40px rgba(255, 0, 0, 0.4) inset; } .effect7:before, .effect7:after { content:""; position:absolute; z-index:-1; -webkit-box-shadow:0 0 20px rgba(0,0,0,0.8); -moz-box-shadow:0 0 20px rgba(0,0,0,0.8); box-shadow:0 0 20px rgba(0,0,0,0.8); top:0; bottom:0; left:10px; right:10px; -moz-border-radius:100px / 10px; border-radius:100px / 10px; } .effect7:after { right:10px; left:auto; -webkit-transform:skew(8deg) rotate(3deg); -moz-transform:skew(8deg) rotate(3deg); -ms-transform:skew(8deg) rotate(3deg); -o-transform:skew(8deg) rotate(3deg); transform:skew(8deg) rotate(3deg); } </style></head> <body> <table width=100% border="0" cellpadding="0" cellspacing="0" align="center"> <tr align="center" valign="top"> <td width="18%" > </td> <td width="67%" ><a href="https://www.biospectrumasia.com/" target="_blank"><img src="https://biospectrumasia.com/bundles/interlinksapp/app/app-asia/images/logo.jpg" title="BioSpectrum Asia" alt="BioSpectrum Asia" border="0" align="middle"/></a></td> <td width="15%"> </td> </tr> </table> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr align="center" valign="top"> <td align="center" valign="top" ></td> <td align="center" valign="top" height="14" ></td> <td> </td> </tr> <tr align="center" valign="top" bgcolor="#EEEEEE"> <td width="35%" align="left" valign="middle" bgcolor="#E2E2E2" class="style2"> </td> <td width="22%" height="30" align="left" valign="middle" bgcolor="#E2E2E2" class="style3">BioSpectrum Asia</td> <td width="43%" align="left" valign="middle" bgcolor="#E2E2E2"> </td> </tr> </table> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr align="center" valign="bottom"> <td height="30"><img src="images/dot_line.jpg" width="40" height="16" /><img src="images/purpal_round.png" width="14" height="14" /><img src="images/dot_line.jpg" width="40" height="16" /><img src="images/gray_round.png" width="10" height="16" /><img src="images/dot_line.jpg" width="40" height="16" /></td> </tr> </table> <table width="100%"> <tr align="left" valign="middle"> <td> <table width="675" border="0" cellpadding="0" cellspacing="0" class="border_style1" align="center"> <tr align="left" valign="top"> <td width="601" height="35"> <div style="margin-left:20px; margin-top:"><strong class="style3">BioSpectrum Asia: Subscription Form </strong></div> </td> <td width="70" align="left" bgcolor="#F8F7F7"> </td> </tr> <tr align="left" valign="top"> <td height="513" colspan="2"> <form id="form1" name="form1" method="post" onsubmit="return validate_rsvp()" action="subscription_reg_2_mgz.php"> <table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style2"> <table border="0" cellspacing="0" cellpadding="0"> <tr> <td height="53" valign="middle"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="66%" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td height="10"></td> </tr> <tr > <td align="left" class="gray_text" > Title *</td> <td align="left" class="gray_text" > Firstname *</td> <td align="left" class="gray_text"> Middlename </td> <td align="left" class="gray_text"> Lastname *</td> </tr> <tr> <td width="77" align="left" valign="top" class="gray_text"><select name="title" class="text" id="title"> <option value="">Select</option> <option value="Mr." >Mr.</option> <option value="Mrs." >Mrs.</option> <option value="Ms" >Ms.</option> <option value="Dr." >Dr.</option> <option value="Prof." >Prof.</option> </select></td> <td align="left" class="gray_text" ><input name="firstname" type="text" id="firstname" value="" /></td> <td align="left" class="gray_text"><input name="middlename" type="text" id="middlename" value="" /></td> <td align="left" class="gray_text"><input name="lastname" type="text" id="lastname" value="" /></td> </tr> </table></td> </tr> <tr> <td height="10"></td> </tr> </table> </td> </tr> <tr> <td height="10"></td> </tr> <tr> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Job Title *</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="325" align="left" valign="top"><span class="sitemap-txt"> <input name="job_title" type="text" id="job_title" size="40" maxlength="80" value="" /> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Revenue of your company(in US $)</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="325" align="left" valign="top"><span class="sitemap-txt"> <input name="revenue" type="text" id="revenue" size="40" maxlength="80" value="" /> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> No. of employees</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="325" align="left" valign="top"><span class="sitemap-txt"> <input name="no_employee" type="text" id="no_employee" size="40" maxlength="80" value="" /> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Are you from</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="370" align="left" valign="top"><span class="sitemap-txt"> <select name="are_you_from" id="are_you_from" onchange="showPlan();"> <option value="">-- Select --</option> <option value="Singapore">Singapore</option> <option value="Other than Singapore">Other than Singapore</option> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr id="sub-plan"> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Subscription plan</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="370" align="left" valign="top"><span class="sitemap-txt"> <select name="subscrtion_plan" id="subscrtion_plan"> <option value="">-- Select Plan --</option> <option value="1 Year" class="sing_plan" >1 Year (S$120 - Get 12 issues including special issue)</option> <option value="2 Years" class="sing_plan" >2 Years (S$240 - Get 24 issues including special issue)</option> <option value="1 Year" class="other_plan" >1 Year (S$150 - Get 12 issues including special issue)including postal charges</option> <option value="2 Years" class="other_plan" >2 Years (S$300 - Get 24 issues including special issue)including postal charges</option> </select> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Subscribe to E-magazine</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="370" align="left" valign="top"><span class="sitemap-txt"> <select name="flipbook_plan" id="flipbook_plan"> <option value="">-- Select Plan --</option> <option value="1 Year" >1 Year (S$35)</option> <option value="2 Years" >2 Years (S$60)</option> </select> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="53" valign="middle"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="168" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Company *</span></td> <td width="20" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="328" align="left" valign="top"><span class="sitemap-txt"> <input name="company" type="text" id="company" size="40" maxlength="80" value=""/> </span></td> <td width="66" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="53" valign="middle"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="229" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Select Home or Office address ? *</span></td> <td width="10" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="273" align="left" valign="top"><span class="sitemap-txt"> <select name="address_type" id="address_type"> <option value="">Select</option> <option value="Home" >Home</option> <option value="Office" >Office</option> </select> </span></td> <td width="71" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> Address *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="344" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <textarea name="addr" cols="31" rows="3" id="addr"></textarea> </span></td> <td width="67" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> City *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="346" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <input name="city" type="text" class="content-txt-without-alignment" id="city" size="40" maxlength="20" value=""/> </span></td> <td width="65" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="8"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> State *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="346" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <input name="state" type="text" class="content-txt-without-alignment" id="state" size="40" maxlength="20" value="" /> </span></td> <td width="65" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="34%"></td> <td width="34%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> Country *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="346" align="left" valign="top" class="gray_text_no_padding"> <select name="country" id="country" style="width:300px;" > <option value="">Select Country</option> <option value="Afghanistan" selec>Afghanistan</option> <option value="Aland Islands" selec>Aland Islands</option> <option value="Albania" selec>Albania</option> <option value="Algeria" selec>Algeria</option> <option value="American Samoa" selec>American Samoa</option> <option value="Andorra" selec>Andorra</option> <option value="Angola" selec>Angola</option> <option value="Anguilla" selec>Anguilla</option> <option value="Antarctica" selec>Antarctica</option> <option value="Antigua and Barbuda" selec>Antigua and Barbuda</option> <option value="Argentina" selec>Argentina</option> <option value="Armenia" selec>Armenia</option> <option value="Aruba" selec>Aruba</option> <option value="Australia" selec>Australia</option> <option value="Austria" selec>Austria</option> <option value="Azerbaijan" selec>Azerbaijan</option> <option value="Bahamas" selec>Bahamas</option> <option value="Bahrain" selec>Bahrain</option> <option value="Bangladesh" selec>Bangladesh</option> <option value="Barbados" selec>Barbados</option> <option value="Belarus" selec>Belarus</option> <option value="Belgium" selec>Belgium</option> <option value="Belize" selec>Belize</option> <option value="Benin" selec>Benin</option> <option value="Bermuda" selec>Bermuda</option> <option value="Bhutan" selec>Bhutan</option> <option value="Bolivia" selec>Bolivia</option> <option value="Bosnia and Herzegovina" selec>Bosnia and Herzegovina</option> <option value="Botswana" selec>Botswana</option> <option value="Bouvet Island" selec>Bouvet Island</option> <option value="Brazil" selec>Brazil</option> <option value="British Virgin Islands" selec>British Virgin Islands</option> <option value="Brunei" selec>Brunei</option> <option value="Bulgaria" selec>Bulgaria</option> <option value="Burkina Faso" selec>Burkina Faso</option> <option value="Burundi" selec>Burundi</option> <option value="Cambodia" selec>Cambodia</option> <option value="Cameroon" selec>Cameroon</option> <option value="Canada" selec>Canada</option> <option value="Cape Verde" selec>Cape Verde</option> <option value="Cayman Islands" selec>Cayman Islands</option> <option value="Central African Republic" selec>Central African Republic</option> <option value="Chad" selec>Chad</option> <option value="Chile" selec>Chile</option> <option value="China" selec>China</option> <option value="Christmas Island" selec>Christmas Island</option> <option value="Cocos (Keeling) Islands" selec>Cocos (Keeling) Islands</option> <option value="Colombia" selec>Colombia</option> <option value="Comoros" selec>Comoros</option> <option value="Congo" selec>Congo</option> <option value="Cook Islands" selec>Cook Islands</option> <option value="Costa Rica" selec>Costa Rica</option> <option value="Croatia" selec>Croatia</option> <option value="Cyprus" selec>Cyprus</option> <option value="Czech Republic" selec>Czech Republic</option> <option value="Denmark" selec>Denmark</option> <option value="Disputed Territory" selec>Disputed Territory</option> <option value="Djibouti" selec>Djibouti</option> <option value="Dominica" selec>Dominica</option> <option value="Dominican Republic" selec>Dominican Republic</option> <option value="East Timor" selec>East Timor</option> <option value="Ecuador" selec>Ecuador</option> <option value="Egypt" selec>Egypt</option> <option value="El Salvador" selec>El Salvador</option> <option value="Equatorial Guinea" selec>Equatorial Guinea</option> <option value="Eritrea" selec>Eritrea</option> <option value="Estonia" selec>Estonia</option> <option value="Ethiopia" selec>Ethiopia</option> <option value="Falkland Islands" selec>Falkland Islands</option> <option value="Faroe Islands" selec>Faroe Islands</option> <option value="Federated States of Micronesia" selec>Federated States of Micronesia</option> <option value="Fiji" selec>Fiji</option> <option value="Finland" selec>Finland</option> <option value="France" selec>France</option> <option value="French Guyana" selec>French Guyana</option> <option value="French Polynesia" selec>French Polynesia</option> <option value="French Southern Territories" selec>French Southern Territories</option> <option value="Gabon" selec>Gabon</option> <option value="Gambia" selec>Gambia</option> <option value="Georgia" selec>Georgia</option> <option value="Germany" selec>Germany</option> <option value="Ghana" selec>Ghana</option> <option value="Gibraltar" selec>Gibraltar</option> <option value="Greece" selec>Greece</option> <option value="Greenland" selec>Greenland</option> <option value="Grenada" selec>Grenada</option> <option value="Guadeloupe" selec>Guadeloupe</option> <option value="Guam" selec>Guam</option> <option value="Guatemala" selec>Guatemala</option> <option value="Guinea" selec>Guinea</option> <option value="Guinea-Bissau" selec>Guinea-Bissau</option> <option value="Guyana" selec>Guyana</option> <option value="Haiti" selec>Haiti</option> <option value="Honduras" selec>Honduras</option> <option value="Hong Kong" selec>Hong Kong</option> <option value="Hungary" selec>Hungary</option> <option value="Iceland" selec>Iceland</option> <option value="India" selec>India</option> <option value="Indonesia" selec>Indonesia</option> <option value="Iraq" selec>Iraq</option> <option value="Iran" selec>Iran</option> <option value="Iraq-Saudi Arabia Neutral Zone" selec>Iraq-Saudi Arabia Neutral Zone</option> <option value="Ireland" selec>Ireland</option> <option value="Israel" selec>Israel</option> <option value="Italy" selec>Italy</option> <option value="Ivory Coast" selec>Ivory Coast</option> <option value="Jamaica" selec>Jamaica</option> <option value="Japan" selec>Japan</option> <option value="Jordan" selec>Jordan</option> <option value="Kazakhstan" selec>Kazakhstan</option> <option value="Kenya" selec>Kenya</option> <option value="Kiribati" selec>Kiribati</option> <option value="Kuwait" selec>Kuwait</option> <option value="Kyrgyzstan" selec>Kyrgyzstan</option> <option value="Laos" selec>Laos</option> <option value="Latvia" selec>Latvia</option> <option value="Lebanon" selec>Lebanon</option> <option value="Lesotho" selec>Lesotho</option> <option value="Liberia" selec>Liberia</option> <option value="Libya" selec>Libya</option> <option value="Liechtenstein" selec>Liechtenstein</option> <option value="Lithuania" selec>Lithuania</option> <option value="Luxembourg" selec>Luxembourg</option> <option value="Macau" selec>Macau</option> <option value="Macedonia" selec>Macedonia</option> <option value="Madagascar" selec>Madagascar</option> <option value="Malawi" selec>Malawi</option> <option value="Malaysia" selec>Malaysia</option> <option value="Maldives" selec>Maldives</option> <option value="Mali" selec>Mali</option> <option value="Malta" selec>Malta</option> <option value="Marshall Islands" selec>Marshall Islands</option> <option value="Martinique" selec>Martinique</option> <option value="Mauritania" selec>Mauritania</option> <option value="Mauritius" selec>Mauritius</option> <option value="Mayotte" selec>Mayotte</option> <option value="Mexico" selec>Mexico</option> <option value="Moldova" selec>Moldova</option> <option value="Monaco" selec>Monaco</option> <option value="Mongolia" selec>Mongolia</option> <option value="Montserrat" selec>Montserrat</option> <option value="Morocco" selec>Morocco</option> <option value="Mozambique" selec>Mozambique</option> <option value="Myanmar" selec>Myanmar</option> <option value="Namibia" selec>Namibia</option> <option value="Nauru" selec>Nauru</option> <option value="Nepal" selec>Nepal</option> <option value="Netherlands" selec>Netherlands</option> <option value="Netherlands Antilles" selec>Netherlands Antilles</option> <option value="New Caledonia" selec>New Caledonia</option> <option value="New Zealand" selec>New Zealand</option> <option value="Nicaragua" selec>Nicaragua</option> <option value="Niger" selec>Niger</option> <option value="Nigeria" selec>Nigeria</option> <option value="Niue" selec>Niue</option> <option value="Norfolk Island" selec>Norfolk Island</option> <option value="North Korea" selec>North Korea</option> <option value="Northern Mariana Islands" selec>Northern Mariana Islands</option> <option value="Norway" selec>Norway</option> <option value="Oman" selec>Oman</option> <option value="Pakistan" selec>Pakistan</option> <option value="Palau" selec>Palau</option> <option value="Palestinian Occupied Territories" selec>Palestinian Occupied Territories</option> <option value="Panama" selec>Panama</option> <option value="Papua New Guinea" selec>Papua New Guinea</option> <option value="Paraguay" selec>Paraguay</option> <option value="Peru" selec>Peru</option> <option value="Philippines" selec>Philippines</option> <option value="Pitcairn Islands" selec>Pitcairn Islands</option> <option value="Poland" selec>Poland</option> <option value="Portugal" selec>Portugal</option> <option value="Puerto Rico" selec>Puerto Rico</option> <option value="Qatar" selec>Qatar</option> <option value="Reunion" selec>Reunion</option> <option value="Romania" selec>Romania</option> <option value="Russia" selec>Russia</option> <option value="Rwanda" selec>Rwanda</option> <option value="Saint Helena and Dependencies" selec>Saint Helena and Dependencies</option> <option value="Saint Kitts and Nevis" selec>Saint Kitts and Nevis</option> <option value="Saint Lucia" selec>Saint Lucia</option> <option value="Saint Pierre and Miquelon" selec>Saint Pierre and Miquelon</option> <option value="Saint Vincent and the Grenadines" selec>Saint Vincent and the Grenadines</option> <option value="Samoa" selec>Samoa</option> <option value="San Marino" selec>San Marino</option> <option value="Sao Tome and Principe" selec>Sao Tome and Principe</option> <option value="Saudi Arabia" selec>Saudi Arabia</option> <option value="Senegal" selec>Senegal</option> <option value="Serbia and Montenegro" selec>Serbia and Montenegro</option> <option value="Seychelles" selec>Seychelles</option> <option value="Sierra Leone" selec>Sierra Leone</option> <option value="Singapore" selec>Singapore</option> <option value="Slovakia" selec>Slovakia</option> <option value="Slovenia" selec>Slovenia</option> <option value="Solomon Islands" selec>Solomon Islands</option> <option value="Somalia" selec>Somalia</option> <option value="South Africa" selec>South Africa</option> <option value="South Korea" selec>South Korea</option> <option value="Spain" selec>Spain</option> <option value="Spratly Islands" selec>Spratly Islands</option> <option value="Sri Lanka" selec>Sri Lanka</option> <option value="Suriname" selec>Suriname</option> <option value="Svalbard and Jan Mayen" selec>Svalbard and Jan Mayen</option> <option value="Swaziland" selec>Swaziland</option> <option value="Sweden" selec>Sweden</option> <option value="Switzerland" selec>Switzerland</option> <option value="Syria" selec>Syria</option> <option value="Taiwan" selec>Taiwan</option> <option value="Tajikistan" selec>Tajikistan</option> <option value="Tanzania" selec>Tanzania</option> <option value="Thailand" selec>Thailand</option> <option value="Togo" selec>Togo</option> <option value="Tokelau" selec>Tokelau</option> <option value="Tonga" selec>Tonga</option> <option value="Trinidad and Tobago" selec>Trinidad and Tobago</option> <option value="Tunisia" selec>Tunisia</option> <option value="Turkey" selec>Turkey</option> <option value="Turkmenistan" selec>Turkmenistan</option> <option value="Turks And Caicos Islands" selec>Turks And Caicos Islands</option> <option value="Tuvalu" selec>Tuvalu</option> <option value="Uganda" selec>Uganda</option> <option value="Ukraine" selec>Ukraine</option> <option value="United Arab Emirates" selec>United Arab Emirates</option> <option value="United Kingdom" selec>United Kingdom</option> <option value="United Nations Neutral Zone" selec>United Nations Neutral Zone</option> <option value="United States" selec>United States</option> <option value="Uruguay" selec>Uruguay</option> <option value="US Virgin Islands" selec>US Virgin Islands</option> <option value="Uzbekistan" selec>Uzbekistan</option> <option value="Vanuatu" selec>Vanuatu</option> <option value="Vatican City" selec>Vatican City</option> <option value="Venezuela" selec>Venezuela</option> <option value="Vietnam" selec>Vietnam</option> <option value="Wallis and Futuna" selec>Wallis and Futuna</option> <option value="Western Sahara" selec>Western Sahara</option> <option value="Yemen" selec>Yemen</option> <option value="Zambia" selec>Zambia</option> <option value="Zimbabwe" selec>Zimbabwe</option> </select> </td> <td width="65" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="8"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> Pincode *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="346" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <input name="pincode" type="text" class="content-txt-without-alignment" id="pincode" size="40" maxlength="20" value="" /> </span></td> <td width="65" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="8"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> Phone number *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="346" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <input name="telephone" type="text" class="content-txt-without-alignment" id="telephone" size="40" maxlength="20" value="" onkeyup="check_num(event,telephone)"/> </span></td> <td width="65" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="50" ><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="44"><table border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="177" align="left" valign="top" class="gray_text_no_padding"> Mobile *</td> <td width="20" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="247" align="left" valign="top"><span class="content-txt-form"> <input name="mob" type="text" class="content-txt-without-alignment" id="mob" size="40" maxlength="20" value="" onkeyup="check_num(event,mob)"/> </span></td> <td width="79" align="center" valign="middle" style="background-repeat:repeat-x;font-family:Arial, Helvetica, sans-serif; font-size:16px;"> </td> <td width="59" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> Email Id *</span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="344" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <input name="email" type="text" id="email" size="40" maxlength="80" value="" /> </span></td> <td width="67" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top"><span class="gray_text_no_padding"><span class="sitemap-txt"> Alternate Email Id </span></span></td> <td align="center"><span class="gray_text_no_padding">:</span></td> <td colspan="2"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="344" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> <input name="alt_email" type="text" id="alt_email" size="40" maxlength="80" value="" /> </span></td> <td width="67" align="left" valign="top" class="gray_text_no_padding"> </td> </tr> </table></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="9"></td> </tr> <tr> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="170" align="left" valign="top" class="gray_text_no_padding"><span class="sitemap-txt"> Payment Mode</span></td> <td width="17" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="325" align="left" valign="top"><span class="sitemap-txt"> <input type = "radio" name="paymode" id="paymode2" value="PayPal" onclick="showPayment();"/>Paypal/ Bank Transfer/ Credit card<br> </span></td> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr id="bt" style="display: none;"> <td height="53"><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="36" align="left"><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="200" align="center" valign="top" class="gray_text_no_padding">Bank Details</td> <tr> <td valign="top" align="left"><span class="gray_text_no_padding"> Company name :</span> </td> <td valign="top"><span class="sitemap-txt">MM Activ Singapore Pte Ltd</span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Bank :</span> </td> <td valign="top"><span class="sitemap-txt">OCBC Bank</span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Account No : </span></td> <td valign="top"><span class="sitemap-txt">USD503179558301<br/> SGD 647875509001 </span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Bank Code : </span></td> <td valign="top"><span class="sitemap-txt">7339</span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Branch Name : </span></td> <td valign="top"><span class="sitemap-txt">North Branch</span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Branch Code : </span></td> <td valign="top"><span class="sitemap-txt">First3digitoftheaccountno </span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Swift Code : </span></td> <td valign="top"><span class="sitemap-txt">OCBCSGSG</span></td> <tr> <tr> <td valign="top"><span class="gray_text_no_padding"> Address : </span></td> <td valign="top"><span class="sitemap-txt">460 North Bridge Road, #01-00, Singapore 188734</span></td> <tr> <td width="70" align="left" valign="top"> </td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="50" ><table width="95%" border="0" align="center" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="100%" height="44"><table border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td width="178" align="left" valign="top" class="gray_text_no_padding"> Enter Verification Code * </td> <td width="10" align="center" valign="top" class="gray_text_no_padding">:</td> <td width="167" align="left" valign="top"><span class="content-txt-form"> <input name="vercode" id="vercode" type="text" class="style56" /> </span></td> <td width="109" align="center" valign="middle" background="images/verify_img_bg.JPG" style="background-repeat:repeat-x;font-family:Arial, Helvetica, sans-serif; font-size:16px;">XIJJJ</td> <td width="120" align="left" valign="top"> <span style="background-repeat:repeat-x;font-family:Arial, Helvetica, sans-serif; font-size:16px;"><span class="content-txt-form"> <input name="test" type="hidden" id="test" value="XIJJJ" /> </span></span></td> </tr> </table></td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <tr> <td height="62" align="center"><table width="95%" border="0" cellpadding="0" cellspacing="0" class="border_style1"> <tr> <td width="29%"></td> <td width="3%" height="10"></td> <td width="43%"></td> <td width="25%"></td> </tr> <tr> <td align="left" valign="top" colspan="3"><span class="gray_text_no_padding"><span class="sitemap-txt"><label><input type="checkbox" value="1" required> I accept the <a href="../pdf/terms-and-conditions.pdf" target="_blank">terms & condition</a> & <a href="../pdf/privacy-policy.pdf" target="_blank">Privacy policy</a></label></span></span></td> </tr> <tr> <td height="10"></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="23" class="gray_text_no_padding"><span class="sitemap-txt"> Note : Fax this form with your cheque/DD/Bank transfer details to :(+65) 63369145 or scan <br> & e-mail to saradha.mani@mmactiv.com </span></td> </tr> <tr> <td align="center"><span class="sitemap-txt"> <input type="submit" name="Submit" value="Submit" /> </span></td> </tr> <tr> <td> </td> </tr> <tr> <td> </td> </tr> </table> </form> </td> </tr> </table> </td> </tr> </table> <p> </p> </body> </html>