signup.html

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<head>
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    <link rel="shortcut icon" href="ico/favicon.ico">
    <title>Billistic.com | Online Bill Management | Sign Up</title>
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    <link href="css/style.css" rel="stylesheet">
    <!--<link href="css/billistic.css" rel="stylesheet">-->
</head>
<body>
<div id="page">
	<div class="content">
		<div class="inner-container">
			<a href="/billistic">
				<img src="img/header_logo_bw.png" class="inner_logo" alt="Billistic"/>
			</a>
			<div></div>
			<div class="header-with-line">
				<span>SIGN UP</span>
			</div>
			<div></div>
			<form action="" method="post" name="signupForm">
				<input type="text" id="firstName" name="firstName" placeholder="First Name" required="required" />
				<input type="text" id="lastName" name="lastName" placeholder="Last Name" required="required" />
				<input type="email" id="email" name="email" placeholder="Email Address" required="required" required="required" />
				<input type="tel" id="mobileNumber" name="mobileNumber" placeholder="Mobile Number for Text Notify" />
				
				<div class="">
					<select id="mobileType" name="mobileType" placeholder="Mobile Device Type">
						<option> Please select </option>
						<option>Type one</option>
						<option>Type two</option>
						<option>Type three</option>
					</select>
				</div>
				
				<input type="text" id="notificationMethod" name="notificationMethod" placeholder="Preferred Notification Method" />
				<input type="email" id="billisticEmail" name="billisticEmail" placeholder="Billistic Email Address - Billers to Use" required="required" />

				<input type="text" id="username" name="username" placeholder="User Name or Email" required="required" />
				<input type="password" id="password" name="password" placeholder="Password"  required="required"/>

				<div class="">
					<select id="mobileType" name="mobileType" placeholder="Select Challenge Question">
						<option> Please select </option>
						<option>What's the zip code for the hospital you were born in?</option>
						<option>Who's your great grandfather's favorite comedian</option>
						<option>What is the middle name of your third-cousin twice-removed?</option>
						<option>Who is the favorite artist of your first pet?</option>
					</select>
				</div>

				<input type="text" id="challengeAnswer" name="challengeAnswer" placeholder="Challenge Answer" />

				<div class="">
					<select id="mobileType" name="mobileType" placeholder="Enter Name of Company that Bills You">
						<option> Please select </option>
						<option>AT&T Wireless</option>
						<option>Aurora Water</option>
						<option>Comcast</option>
						<option>SallieMae College Loan</option>
						<option>Xcel Energy</option>
						<option>Verizon Business</option>
						<option>Verizon Communications</option>
						<option>Verizon Online</option>
						<option>Verizon Wireless</option>
					</select>
				</div>
				<input type="submit" value="SIGN UP" style="background-color:#18a8c2;color:#fff;border:3px solid #18a8c2">
		</form>
		</div>
    </div>
</div>
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</body>
</html>