<?php /* Template Name: member-new */ ?>


<?php get_header(); ?>
<?php putRevSlider("slidemem") ?>
<!-- ________________________________ :BEGIN: Three Fearures Wrapper ________________________________ -->
 <?php
include("sub-header.php");
?>
<!-- ________________________________ :END: Three Fearures Wrapper ________________________________ -->
        


	
	<div class="container-fluid">

<div class="container padding-bottom-standard padding-top-standard contact-us-page">
    <h1 class="underborder-title text-right">عضویت باشگاه مشتریان</h1>

    <div class="row">
        <form action="" class="row-fluid m3g-form contact-us" method="post">
            <!-- Personal Info -->
            <div class="col-xs-12 clr">
                <h2 class="clr row-fluid text-right color-unimportant"><i class="icon-m3g-user"></i> اطلاعات شخصی</h2>
                <div class="row-fluid">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="FirstName" placeholder="نام" required="">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="LastName" placeholder="نام خانوادگی" required="">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="FathersName" placeholder="نام پدر" required="">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="NationalId" placeholder="کد ملی" required="">
                    <div class="col-xs-12 col-md-12 margin-bottom-half">
                        <label>تاریخ تولد</label>
                        <div class="row birthdate-selectors">
                            <select class="col-xs-4 day m3g-input m3g-input-medium" required="">
                                <option value="">روز (انتخاب کنید)</option>
                                    <option value="1">1</option>
                                    <option value="2">2</option>
                                    <option value="3">3</option>
                                    <option value="4">4</option>
                                    <option value="5">5</option>
                                    <option value="6">6</option>
                                    <option value="7">7</option>
                                    <option value="8">8</option>
                                    <option value="9">9</option>
                                    <option value="10">10</option>
                                    <option value="11">11</option>
                                    <option value="12">12</option>
                                    <option value="13">13</option>
                                    <option value="14">14</option>
                                    <option value="15">15</option>
                                    <option value="16">16</option>
                                    <option value="17">17</option>
                                    <option value="18">18</option>
                                    <option value="19">19</option>
                                    <option value="20">20</option>
                                    <option value="21">21</option>
                                    <option value="22">22</option>
                                    <option value="23">23</option>
                                    <option value="24">24</option>
                                    <option value="25">25</option>
                                    <option value="26">26</option>
                                    <option value="27">27</option>
                                    <option value="28">28</option>
                                    <option value="29">29</option>
                                    <option value="30">30</option>
                                    <option value="31">31</option>
                            </select>
                            <select class="col-xs-4 month m3g-input m3g-input-medium" required="">
                                <option value="">ماه (انتخاب کنید)</option>
                                    <option value="1">1</option>
                                    <option value="2">2</option>
                                    <option value="3">3</option>
                                    <option value="4">4</option>
                                    <option value="5">5</option>
                                    <option value="6">6</option>
                                    <option value="7">7</option>
                                    <option value="8">8</option>
                                    <option value="9">9</option>
                                    <option value="10">10</option>
                                    <option value="11">11</option>
                                    <option value="12">12</option>
                            </select>
                            <select class="col-xs-4 year m3g-input m3g-input-medium" required="">
                                <option value="">سال (انتخاب کنید)</option>
                                    <option value="1380">1380</option>
                                    <option value="1381">1381</option>
                                    <option value="1382">1382</option>
                                    <option value="1383">1383</option>
                                    <option value="1384">1384</option>
                                    <option value="1385">1385</option>
                                    <option value="1386">1386</option>
                                    <option value="1387">1387</option>
                                    <option value="1388">1388</option>
                                    <option value="1389">1389</option>
                                    <option value="1390">1390</option>
                                    <option value="1391">1391</option>
                            </select>
                        </div>
                        <input type="hidden" name="BirthDate" value="1370-12-18">
                    </div>
                </div>
            </div>

            <!-- Contact Info -->
            <div class="col-xs-12 clr">
                <h2 class="clr row-fluid text-right color-unimportant"><i class="icon-m3g-phone"></i> اطلاعات تماس</h2>
                <div class="row-fluid">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="LandLine" placeholder="تلفن ثابت" required="">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="CellPhone" placeholder="تلفن همراه" required="">
                    <input type="email" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="Email" placeholder="آدرس ایمیل" required="">
                    <input type="text" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" name="Address" placeholder="نشانی محل سکونت" required="">
                </div>
            </div>

            <!-- Other Info -->
            <div class="col-xs-12 clr">
                <h2 class="clr row-fluid text-right color-unimportant"><i class="icon-m3g-info-with-circle"></i> اطلاعات تکمیلی</h2>
                <div class="row-fluid">
                    <select name="AcademicField" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" required="">
                        <option value="">رشته تحصیلی (انتخاب کنید)</option>
                        <option value="ریاضیات">ریاضیات</option>
                        <option value="علوم تجربی">علوم تجربی</option>
                        <option value="ادبیات">ادبیات</option>
                    </select>

                    <select name="FavoriteMusicGenre" tabindex="0" class="col-xs-12 col-md-6 margin-bottom-half m3g-input m3g-input-medium" required="">
                        <option value="">سبک موسیقی موردعلاقه (انتخاب کنید)</option>
                        <option value="سنتی">سنتی</option>
                        <option value="پاپ">پاپ</option>
                        <option value="راک">راک</option>
                        <option value="بلوز">بلوز</option>
                        <option value="متال">متال</option>
                        <option value="رپ">رپ</option>
                    </select>

                    <input type="text" required="" class="col-xs-12 col-md-12 margin-bottom-half m3g-input m3g-input-medium" name="FavoriteRestaurantAndFood" placeholder="بهترین رستوران و غذا از دید شما">

                    <input type="text" required="" class="col-xs-12 col-md-12 margin-bottom-half m3g-input m3g-input-medium" name="FavoriteHobbyOrSkill" placeholder="مهارت خاص یا علاقه شخصی">

                    <input type="text" required="" class="col-xs-12 col-md-12 margin-bottom-half m3g-input m3g-input-medium" name="FavoriteSport" placeholder="ورزش موردعلاقه">

                    <input type="text" required="" class="col-xs-12 col-md-12 margin-bottom-half m3g-input m3g-input-medium" name="FavoriteMovie" placeholder="بهترین فیلم از دید شما">

                    <input type="text" required="" class="col-xs-12 col-md-12 margin-bottom-half m3g-input m3g-input-medium" name="FavoriteEntertainment" placeholder="بهترین تفریح به نظر شما">
                </div>
            </div>

            <div class="row-fluid text-left">
                <div class="col-xs-12">
                    <input type="submit" class="m3g-button m3g-button-identical m3g-button-medium m3g-input-medium" value="ارسال">
                </div>
            </div>
        </form>
    </div>
</div>

<script type="text/javascript">
        var pageName = 'YouthClubApplicationPage';
</script>

    </div>
	





	
	
</section>


<?php get_footer(); ?>
	
	
    </div>
    <!-- ________________________________ :END: Main Container ________________________________ -->
    <!-- ________________________________ :BEGIN: Scripts ________________________________ -->
    <script type="text/javascript">
        var applicationConfig = {
            language: "fa" || "fa"
        };
    </script>
    <script type="text/javascript" src="/wp-content/themes/mizbanetabatat/assets/lib/jQuery/jquery-1.12.4.min.js"></script>
    <script type="text/javascript" src="/wp-content/themes/mizbanetabatat/Assets1/js/app-bundle.min.js?v=1"></script>
        <script type="text/javascript" src="/wp-content/themes/mizbanetabatat/assets/js/hyperform.fa.js"></script>
    
    <!-- ________________________________ :END: Scripts ________________________________ -->
</body>
</html>