<div class="order-page-left"><div class="text-notification" style="display:none;"></div><form id="orderForm" action="" method="post"><h3>YOUR CONTACT INFORMATION</h3> <div class="text-tier1 text-tier clearfix"> <div class="column-order column-order3"> <div class="column-order-in"><input type="text" name="cunstomer_first_name" placeholder="First Name"/></div></div><div class="column-order column-order3"> <div class="column-order-in"><input type="text" name="customer_middle_name" placeholder="Middle Name"/></div></div><div class="column-order column-order3"> <div class="column-order-in"><input type="text" name="customer_last_name" placeholder="Last Name"/></div></div></div><div class="text-tier2 text-tier clearfix"> <div class="column-order column-order2"> <div class="column-order-in"><input type="tel" name="customer_phone" placeholder="Phone Number"/> <div class="text-description"> Notification will be sent automated via text message Notification will be sent automated via text message </div></div></div><div class="column-order column-order2"> <div class="column-order-in"><input type="email" name="customer_email" placeholder="Email Address"/> <div class="text-description"> Notification will be sent automated via text message Notification will be sent automated via text message </div></div></div></div><div class="text-tier text-tier clearfix"> <div class="column-order-in"><input type="checkbox" name="customer_infor_addtional_product"/> <span>I want information about additional product and service offers send me via text message</span> <div class="text-description"> Notification will be sent automated via text message Notification will be sent automated via text message </div></div></div><div class="text-tier text-tier clearfix"> <div class="column-order-in"> <div class="label-title">What language would you like us to use for future communication ?</div><p><input type="radio" name="customer_language" value="English"/> <span>English</span></p><p><input type="radio" name="customer_language" value="Spanish"/> <span>Spanish</span></p></div></div><h3>YOUR SERVICE INFORMATION</h3> <div class="text-tier text-tier clearfix"> <div class="column-order-in"> <div class="label-title">Do you want to turn on new service or switch to V247Power from another provider ? </div><p><input type="radio" name="customer_moving_switching" value="I’m moving"/> <span>I’m moving</span></p><p><input type="radio" name="customer_moving_switching" value="I’m switching"/> <span>I’m switching</span></p><div class="text-description"> Notification will be sent automated via text message Notification will be sent automated via text message </div></div></div><h3>YOUR BILLING & PERSONAL INFORMATION</h3> <div class="text-tier text-tier clearfix"> <div class="column-order column-order2"> <div class="column-order-in"><input type="text" name="customer_social_security_number" placeholder="Social Sercurity Number"/></div></div></div><div class="text-tier text-tier clearfix"> <div class="column-order-in"> <div class="label-title">Would you like to reduce your clutter and receive e-bills ?</div><p><input type="radio" name="customer_reduce_clutter_ebill" value="Yes"/> <span>Yes</span></p><p><input type="radio" name="customer_reduce_clutter_ebill" value="No"/> <span>No</span></p></div></div><div class="text-tier1 text-tier clearfix"> <div class="column-order column-order5"> <div class="column-order-in"><input type="text" name="customer_billing_address" placeholder="Billing Address"/></div></div><div class="column-order column-order5"> <div class="column-order-in"><input type="text" name="customer_billing_apt" placeholder="Apt/Suite"/></div></div><div class="column-order column-order5"> <div class="column-order-in"><input type="text" name="customer_billing_city" placeholder="City"/></div></div><div class="column-order column-order5"> <div class="column-order-in"><input type="text" name="customer_billing_state" placeholder="State"/></div></div><div class="column-order column-order5"> <div class="column-order-in"><input type="text" name="customer_billing_zipcode" placeholder="Zip"/></div></div></div><div class="text-tier text-tier clearfix"> <div class="column-order column-order2"> <div class="column-order-in"> <div class="label-title">If you have a promotion code, enter it here:</div><input type="text" name="customer_promotion_code"/></div></div></div><div class="text-tier text-tier clearfix"> <div class="column-order column-order2"> <div class="column-order-in"> <div class="label-title">If you have a Referral Id, enter it here:</div><input type="text" name="customer_referral_id"/></div></div></div><h3>YOUR BILLING & PERSONAL INFORMATION</h3> <div class="text-tier text-tier clearfix"> <div class="column-order"> <div class="column-order-in"> <div class="label-title">Give a username and password to access your account online</div><div class="text-description"> Username and password must be 8-18 characters in length</div></div></div></div><div class="text-tier text-tier clearfix"> <div class="column-order column-order3"> <div class="column-order-in"><input type="text" name="customer_username" placeholder="Username"/></div></div><div class="column-order column-order3"> <div class="column-order-in"><input type="password" name="customer_password" placeholder="Password"/></div></div><div class="column-order column-order3"> <div class="column-order-in"><input type="password" name="customer_password_2" placeholder="Comfirm PassWord"/></div></div></div><div class="text-tier text-tier clearfix button-submit"> <div class="column-order-in"><p><input type="checkbox" name="customer_agree_terms" value="1"/> <span>I confirm my enrollment service and I have read, understand and agree to the Terms of Services and Your Right As A Customer. </span> </p><p><input type="submit" value="Submit"/></p></div></div><input type="text" hidden="hidden" name="product_id" value="0"/> <input type="text" hidden="hidden" name="product_name" value=""/> <input type="text" hidden="hidden" name="product_price" value="0"/> </form><img src="https://dev.v247power.com/wp-content/themes/Divi/images/ajax-loader.gif" id="imgLoader" style="display: none;"></div>