
            <div id="overlay-back"></div>
            <div id="overlay">
                <div class="spinner-border pre-loading" role="status">
                    <i class="fa fa-3x fa-spinner fa-spin"></i>
                </div>
            </div>
            <div id="seaade_registration_form">
                <form id="mad-job-application-form" name="registration" enctype="multipart/form-data" action="/seaade/wp-json/wp/v2/pages/6709" method="POST">
                    
                    
                    <legend>
                        Personal Details
                        <span id="current-time" style="font-size:16px" class="float-right"></span>
                    </legend>
                    
                    <div class="container">
                        <div class="row justify-content-center">
                            <div class="col-md-6 offset-md-2 pt-4">
                                <div class="input-block">
                                    <label class="form-check-label pb-3 pr-4">Please choose the registration category <span class="error">*</span></label><br/>
                                    <div class="custom-control custom-radio custom-control-inline career">
                                        <input type="radio" id="dentist" name="occupation" value="dentist" class="custom-control-input">
                                        <label class="custom-control-label" for="dentist">SEAADE Member</label>
                                    </div>
                                    <div class="custom-control custom-radio custom-control-inline career">
                                        <input type="radio" id="non-member" name="occupation" value="non-member" class="custom-control-input">
                                        <label class="custom-control-label" for="non-member">SEAADE Non-Member</label>
                                    </div>
                                    <div class="custom-control custom-radio custom-control-inline career">
                                        <input type="radio" value="student" id="student" name="occupation" class="custom-control-input">
                                        <label class="custom-control-label" for="student">Student</label>
                                        <label id="occupationMsg">&nbsp;&nbsp;</label>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="form-group row">
                        <div class="col-md-6 col-sm-12  mb-lg-0 pt-4">
                            <input class="form-control" type="text" name="fullname" id="fullname" placeholder="Full name as in passport *" aria-label="Full Name">
                            <div class="message fullname"></div>
                        </div>
                        <div class="col-md-6 col-sm-12 pt-3">
                            <div class="input-block">
                                <label class="form-check-label pb-1 pr-4">Gender <span class="error">*</span></label><br/>
                                <div class="custom-control custom-radio custom-control-inline">
                                    <input type="radio" id="female" name="gender" value="female" class="custom-control-input">
                                    <label class="custom-control-label" for="female">Female</label>
                                </div>
                                <div class="custom-control custom-radio custom-control-inline">
                                    <input type="radio" value="male" id="male" name="gender" class="custom-control-input">
                                    <label class="custom-control-label" for="male">Male</label>
                                </div>
                                <div class="custom-control custom-radio custom-control-inline">
                                    <input type="radio" value="Other" id="other-gender" name="gender" class="custom-control-input">
                                    <label class="custom-control-label" for="other-gender">Other</label>
                                    <label id="requestGender">&nbsp;&nbsp;</label>
                                </div>
                            </div>
                        </div>
                        <div style="display:none" class="total-price">Total amount: <lable style="color:#2d358e;" class="total-amount"></lable></div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <input class="form-control" type="email" name="email" id="email" placeholder="Email *" aria-label="Email">
                            <div class="message email"></div>
                        </div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <input class="form-control" type="text" name="phone" id="phone" placeholder="Phone number (with country code) *" aria-label="Phone">
                            <div class="message phone"></div>
                        </div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <input class="form-control" id="nationality" name="nationality" type="text" placeholder="Nationality *" aria-label="Nationality">
                            <div class="message nationality"></div>   
                        </div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <div class="input-block">
                                <select class="form-control custom-select" id="country" name="country">
                                    <option selected value="">Select country *</option>
                                    <option value="Afghanistan">Afghanistan</option>
                                    <option value="Åland Islands">Åland Islands</option>
                                    <option value="Albania">Albania</option>
                                    <option value="Algeria">Algeria</option>
                                    <option value="American Samoa">American Samoa</option>
                                    <option value="Andorra">Andorra</option>
                                    <option value="Angola">Angola</option>
                                    <option value="Anguilla">Anguilla</option>
                                    <option value="Antarctica">Antarctica</option>
                                    <option value="Antigua and Barbuda">Antigua and Barbuda</option>
                                    <option value="Argentina">Argentina</option>
                                    <option value="Armenia">Armenia</option>
                                    <option value="Aruba">Aruba</option>
                                    <option value="Australia">Australia</option>
                                    <option value="Austria">Austria</option>
                                    <option value="Azerbaijan">Azerbaijan</option>
                                    <option value="Bahamas">Bahamas</option>
                                    <option value="Bahrain">Bahrain</option>
                                    <option value="Bangladesh">Bangladesh</option>
                                    <option value="Barbados">Barbados</option>
                                    <option value="Belarus">Belarus</option>
                                    <option value="Belgium">Belgium</option>
                                    <option value="Belize">Belize</option>
                                    <option value="Benin">Benin</option>
                                    <option value="Bermuda">Bermuda</option>
                                    <option value="Bhutan">Bhutan</option>
                                    <option value="Bolivia">Bolivia</option>
                                    <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
                                    <option value="Botswana">Botswana</option>
                                    <option value="Bouvet Island">Bouvet Island</option>
                                    <option value="Brazil">Brazil</option>
                                    <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
                                    <option value="Brunei Darussalam">Brunei Darussalam</option>
                                    <option value="Bulgaria">Bulgaria</option>
                                    <option value="Burkina Faso">Burkina Faso</option>
                                    <option value="Burundi">Burundi</option>
                                    <option value="Cambodia">Cambodia</option>
                                    <option value="Cameroon">Cameroon</option>
                                    <option value="Canada">Canada</option>
                                    <option value="Cape Verde">Cape Verde</option>
                                    <option value="Cayman Islands">Cayman Islands</option>
                                    <option value="Central African Republic">Central African Republic</option>
                                    <option value="Chad">Chad</option>
                                    <option value="Chile">Chile</option>
                                    <option value="China">China</option>
                                    <option value="Christmas Island">Christmas Island</option>
                                    <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
                                    <option value="Colombia">Colombia</option>
                                    <option value="Comoros">Comoros</option>
                                    <option value="Congo">Congo</option>
                                    <option value="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</option>
                                    <option value="Cook Islands">Cook Islands</option>
                                    <option value="Costa Rica">Costa Rica</option>
                                    <option value="Cote D'ivoire">Cote D'ivoire</option>
                                    <option value="Croatia">Croatia</option>
                                    <option value="Cuba">Cuba</option>
                                    <option value="Cyprus">Cyprus</option>
                                    <option value="Czech Republic">Czech Republic</option>
                                    <option value="Denmark">Denmark</option>
                                    <option value="Djibouti">Djibouti</option>
                                    <option value="Dominica">Dominica</option>
                                    <option value="Dominican Republic">Dominican Republic</option>
                                    <option value="Ecuador">Ecuador</option>
                                    <option value="Egypt">Egypt</option>
                                    <option value="El Salvador">El Salvador</option>
                                    <option value="Equatorial Guinea">Equatorial Guinea</option>
                                    <option value="Eritrea">Eritrea</option>
                                    <option value="Estonia">Estonia</option>
                                    <option value="Ethiopia">Ethiopia</option>
                                    <option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
                                    <option value="Faroe Islands">Faroe Islands</option>
                                    <option value="Fiji">Fiji</option>
                                    <option value="Finland">Finland</option>
                                    <option value="France">France</option>
                                    <option value="French Guiana">French Guiana</option>
                                    <option value="French Polynesia">French Polynesia</option>
                                    <option value="French Southern Territories">French Southern Territories</option>
                                    <option value="Gabon">Gabon</option>
                                    <option value="Gambia">Gambia</option>
                                    <option value="Georgia">Georgia</option>
                                    <option value="Germany">Germany</option>
                                    <option value="Ghana">Ghana</option>
                                    <option value="Gibraltar">Gibraltar</option>
                                    <option value="Greece">Greece</option>
                                    <option value="Greenland">Greenland</option>
                                    <option value="Grenada">Grenada</option>
                                    <option value="Guadeloupe">Guadeloupe</option>
                                    <option value="Guam">Guam</option>
                                    <option value="Guatemala">Guatemala</option>
                                    <option value="Guernsey">Guernsey</option>
                                    <option value="Guinea">Guinea</option>
                                    <option value="Guinea-bissau">Guinea-bissau</option>
                                    <option value="Guyana">Guyana</option>
                                    <option value="Haiti">Haiti</option>
                                    <option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>
                                    <option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
                                    <option value="Honduras">Honduras</option>
                                    <option value="Hong Kong">Hong Kong</option>
                                    <option value="Hungary">Hungary</option>
                                    <option value="Iceland">Iceland</option>
                                    <option value="India">India</option>
                                    <option value="Indonesia">Indonesia</option>
                                    <option value="Iran, Islamic Republic of">Iran, Islamic Republic of</option>
                                    <option value="Iraq">Iraq</option>
                                    <option value="Ireland">Ireland</option>
                                    <option value="Isle of Man">Isle of Man</option>
                                    <option value="Israel">Israel</option>
                                    <option value="Italy">Italy</option>
                                    <option value="Jamaica">Jamaica</option>
                                    <option value="Japan">Japan</option>
                                    <option value="Jersey">Jersey</option>
                                    <option value="Jordan">Jordan</option>
                                    <option value="Kazakhstan">Kazakhstan</option>
                                    <option value="Kenya">Kenya</option>
                                    <option value="Kiribati">Kiribati</option>
                                    <option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
                                    <option value="Korea, Republic of">Korea, Republic of</option>
                                    <option value="Kuwait">Kuwait</option>
                                    <option value="Kyrgyzstan">Kyrgyzstan</option>
                                    <option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
                                    <option value="Latvia">Latvia</option>
                                    <option value="Lebanon">Lebanon</option>
                                    <option value="Lesotho">Lesotho</option>
                                    <option value="Liberia">Liberia</option>
                                    <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
                                    <option value="Liechtenstein">Liechtenstein</option>
                                    <option value="Lithuania">Lithuania</option>
                                    <option value="Luxembourg">Luxembourg</option>
                                    <option value="Macao">Macao</option>
                                    <option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</option>
                                    <option value="Madagascar">Madagascar</option>
                                    <option value="Malawi">Malawi</option>
                                    <option value="Malaysia">Malaysia</option>
                                    <option value="Maldives">Maldives</option>
                                    <option value="Mali">Mali</option>
                                    <option value="Malta">Malta</option>
                                    <option value="Marshall Islands">Marshall Islands</option>
                                    <option value="Martinique">Martinique</option>
                                    <option value="Mauritania">Mauritania</option>
                                    <option value="Mauritius">Mauritius</option>
                                    <option value="Mayotte">Mayotte</option>
                                    <option value="Mexico">Mexico</option>
                                    <option value="Micronesia, Federated States of">Micronesia, Federated States of</option>
                                    <option value="Moldova, Republic of">Moldova, Republic of</option>
                                    <option value="Monaco">Monaco</option>
                                    <option value="Mongolia">Mongolia</option>
                                    <option value="Montenegro">Montenegro</option>
                                    <option value="Montserrat">Montserrat</option>
                                    <option value="Morocco">Morocco</option>
                                    <option value="Mozambique">Mozambique</option>
                                    <option value="Myanmar">Myanmar</option>
                                    <option value="Namibia">Namibia</option>
                                    <option value="Nauru">Nauru</option>
                                    <option value="Nepal">Nepal</option>
                                    <option value="Netherlands">Netherlands</option>
                                    <option value="Netherlands Antilles">Netherlands Antilles</option>
                                    <option value="New Caledonia">New Caledonia</option>
                                    <option value="New Zealand">New Zealand</option>
                                    <option value="Nicaragua">Nicaragua</option>
                                    <option value="Niger">Niger</option>
                                    <option value="Nigeria">Nigeria</option>
                                    <option value="Niue">Niue</option>
                                    <option value="Norfolk Island">Norfolk Island</option>
                                    <option value="Northern Mariana Islands">Northern Mariana Islands</option>
                                    <option value="Norway">Norway</option>
                                    <option value="Oman">Oman</option>
                                    <option value="Pakistan">Pakistan</option>
                                    <option value="Palau">Palau</option>
                                    <option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
                                    <option value="Panama">Panama</option>
                                    <option value="Papua New Guinea">Papua New Guinea</option>
                                    <option value="Paraguay">Paraguay</option>
                                    <option value="Peru">Peru</option>
                                    <option value="Philippines">Philippines</option>
                                    <option value="Pitcairn">Pitcairn</option>
                                    <option value="Poland">Poland</option>
                                    <option value="Portugal">Portugal</option>
                                    <option value="Puerto Rico">Puerto Rico</option>
                                    <option value="Qatar">Qatar</option>
                                    <option value="Reunion">Reunion</option>
                                    <option value="Romania">Romania</option>
                                    <option value="Russian Federation">Russian Federation</option>
                                    <option value="Rwanda">Rwanda</option>
                                    <option value="Saint Helena">Saint Helena</option>
                                    <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
                                    <option value="Saint Lucia">Saint Lucia</option>
                                    <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
                                    <option value="Saint Vincent and The Grenadines">Saint Vincent and The Grenadines</option>
                                    <option value="Samoa">Samoa</option>
                                    <option value="San Marino">San Marino</option>
                                    <option value="Sao Tome and Principe">Sao Tome and Principe</option>
                                    <option value="Saudi Arabia">Saudi Arabia</option>
                                    <option value="Senegal">Senegal</option>
                                    <option value="Serbia">Serbia</option>
                                    <option value="Seychelles">Seychelles</option>
                                    <option value="Sierra Leone">Sierra Leone</option>
                                    <option value="Singapore">Singapore</option>
                                    <option value="Slovakia">Slovakia</option>
                                    <option value="Slovenia">Slovenia</option>
                                    <option value="Solomon Islands">Solomon Islands</option>
                                    <option value="Somalia">Somalia</option>
                                    <option value="South Africa">South Africa</option>
                                    <option value="South Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</option>
                                    <option value="Spain">Spain</option>
                                    <option value="Sri Lanka">Sri Lanka</option>
                                    <option value="Sudan">Sudan</option>
                                    <option value="Suriname">Suriname</option>
                                    <option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
                                    <option value="Swaziland">Swaziland</option>
                                    <option value="Sweden">Sweden</option>
                                    <option value="Switzerland">Switzerland</option>
                                    <option value="Syrian Arab Republic">Syrian Arab Republic</option>
                                    <option value="Taiwan">Taiwan</option>
                                    <option value="Tajikistan">Tajikistan</option>
                                    <option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
                                    <option value="Thailand">Thailand</option>
                                    <option value="Timor-leste">Timor-leste</option>
                                    <option value="Togo">Togo</option>
                                    <option value="Tokelau">Tokelau</option>
                                    <option value="Tonga">Tonga</option>
                                    <option value="Trinidad and Tobago">Trinidad and Tobago</option>
                                    <option value="Tunisia">Tunisia</option>
                                    <option value="Turkey">Turkey</option>
                                    <option value="Turkmenistan">Turkmenistan</option>
                                    <option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
                                    <option value="Tuvalu">Tuvalu</option>
                                    <option value="Uganda">Uganda</option>
                                    <option value="Ukraine">Ukraine</option>
                                    <option value="United Arab Emirates">United Arab Emirates</option>
                                    <option value="United Kingdom">United Kingdom</option>
                                    <option value="United States">United States</option>
                                    <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
                                    <option value="Uruguay">Uruguay</option>
                                    <option value="Uzbekistan">Uzbekistan</option>
                                    <option value="Vanuatu">Vanuatu</option>
                                    <option value="Venezuela">Venezuela</option>
                                    <option value="Viet Nam">Viet Nam</option>
                                    <option value="Virgin Islands, British">Virgin Islands, British</option>
                                    <option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
                                    <option value="Wallis and Futuna">Wallis and Futuna</option>
                                    <option value="Western Sahara">Western Sahara</option>
                                    <option value="Yemen">Yemen</option>
                                    <option value="Zambia">Zambia</option>
                                    <option value="Zimbabwe">Zimbabwe</option>
                                </select>
                            </div>
                            <div class="message country"></div>   
                        </div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <input class="form-control" id="hospital_university_name" name="hospital_university_name" type="text" placeholder="Hospital/University name" aria-label="Nationality">
                            <div class="message hospital_university_name"></div>   
                        </div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <input class="form-control" id="position" name="position" type="text" placeholder="Position *" aria-label="Position">
                            <div class="error-message position"></div>   
                        </div>
                        <div class="col-md-6 col-sm-12 pt-4">
                            <div class="input-block">
                                <label class="form-check-label pb-3 pr-4">Dietary Preference <span class="error">*</span></label><br/>
                                <div class="custom-control custom-radio custom-control-inline Dietary">
                                    <input type="radio" id="non_preference" name="dietary_preference" value="No preference" class="custom-control-input">
                                    <label class="custom-control-label" for="non_preference">No preference</label>
                                </div>
                                <div class="custom-control custom-radio custom-control-inline Dietary">
                                    <input type="radio" value="Vegetarian" id="vegetarian" name="dietary_preference" class="custom-control-input">
                                    <label class="custom-control-label" for="vegetarian">Vegetarian</label>
                                </div>
                                <div class="custom-control custom-radio custom-control-inline Dietary">
                                    <input type="radio" value="Halal" id="halal" name="dietary_preference" class="custom-control-input">
                                    <label class="custom-control-label" for="halal">Halal</label>
                                </div>
                                <div class="custom-control custom-radio custom-control-inline Dietary">
                                    <input type="radio" value="otherDietaryPreference" id="other" name="dietary_preference" class="custom-control-input">
                                    <label class="custom-control-label" for="other">Other</label>
                                    <label id="requestDietaryPreference">&nbsp;&nbsp;</label>
                                </div>
                                <div class="message dietary-other"></div>
                                <input style="display:none;" class="form-control" id="otherDietary" name="otherDietary" for="otherDietary" type="text" aria-label="dietary-other">
                            </div>
                        </div>
                        
                    </div><br/>
                    <legend>Package Information<small style="font-size:16px">: <a target="_blank" href="https://www.puthisastra.edu.kh/seaade/packages">View package details</a></small></legend>
                    <div class="form-group row">
                    
            <br/>
            <div class="col-md-6 col-sm-12  mb-lg-0 pt-4">
                <div class="input-block">
                    <label class="form-check-label pb-3 pr-4">Do you want a residential or non-residential package? <span class="error">*</span></label><br/>
                    <div class="custom-control custom-radio custom-control-inline roomType">
                        <input type="radio" value="residential" id="residential" name="residenceType" class="custom-control-input">
                        <label class="custom-control-label" for="residential">Residential</label>
                    </div>
                    <div class="custom-control custom-radio custom-control-inline roomType">
                        <input type="radio" value="Non-residential" id="Non-residential" name="residenceType" class="custom-control-input">
                        <label class="custom-control-label" for="Non-residential">Non-residential</label>
                        <label id="requestMsgPackage">&nbsp;&nbsp;</label>
                    </div>
                </div> 
            </div>
        
                    
            <div class="col-md-6 col-sm-12 pt-5" id="roomType-opt">
                <div class="input-block">
                    <select class="form-control custom-select" id="roomType" name="roomType">
                        <option selected value="">Select room type *</option>
                        <option value="Single">Single</option>
                        <option value="Twin">Twin share (Room shared with other participant)</option>
                    </select>
                </div>
            </div>
        
                    
            <div class="col-md-6 col-sm-12 pt-4" id="twinRoomSharing-opt" style="display:none">
                <div class="input-block">
                    <input class="form-control" id="twinRoomSharing" name="twinRoomSharing" type="text" placeholder="What is the name of the person you wish to share a room with?" aria-label="What is the name of the person you wish to share a room with?">
                </div>
            </div>
        
                    
        <div class="col-md-6 col-sm-12  mb-lg-0 pt-4" id="checkin-date">
            <input readonly type="text" id="fromDate" name="checkin_date" class="form-control" placeholder="Hotel Check-in Date *">
        </div>
    
                    
        <div class="col-md-6 col-sm-12  mb-lg-0 pt-4" id="checkout-date">
            <input readonly type="text" id="toDate" name="checkout_date" class="form-control" placeholder="Hotel Check-out Date *">
        </div>
    
                    
        <div class="col-md-6 col-sm-12  mb-lg-0 pt-3" id="accommodation-opt">
            <div class="input-block">
                <label class="form-check-label pb-3 pr-4">Do you require an additional night accommodation? <span class="error">*</span></label><br/>
                <div class="custom-control custom-radio custom-control-inline accommodation">
                    <input type="radio" value="accommodation_yes" id="accommodation_yes" name="accommodation" class="custom-control-input">
                    <label class="custom-control-label" for="accommodation_yes">Yes (50.00 USD/night)</label>
                </div>
                <div class="custom-control custom-radio custom-control-inline accommodation">
                    <input type="radio" value="accommodation_no" id="accommodation_no" name="accommodation" class="custom-control-input">
                    <label class="custom-control-label" for="accommodation_no">No</label>
                    <label id="accommodationMsg">&nbsp;&nbsp;</label>
                </div>
            </div> 
        </div>
    
                    
        <div style="display:none" class="col-md-6 col-sm-12  mb-lg-0 pt-3" id="additionalaccommodation-opt">
            <div class="input-block">
                <label class="form-check-label pb-3 pr-4">Which day night do you preferred? <span class="error">*</span></label><br/>
                <div class="custom-control custom-radio custom-control-inline additionalaccommodation">
                    <input type="radio" value="23-Nov-2022" id="additionalaccommodation-before" name="additionalaccommodation" class="custom-control-input">
                    <label class="custom-control-label" for="additionalaccommodation-before">23-Nov-2022</label>
                </div>
                <div class="custom-control custom-radio custom-control-inline additionalaccommodation">
                    <input type="radio" value="27-Nov-2022" id="additionalaccommodation-after" name="additionalaccommodation" class="custom-control-input">
                    <label class="custom-control-label" for="additionalaccommodation-after">27-Nov-2022</label>
                    
                </div>
                <div class="custom-control custom-radio custom-control-inline additionalaccommodation">
                    <input type="radio" value="Both" id="additionalaccommodation-both" name="additionalaccommodation" class="custom-control-input">
                    <label class="custom-control-label" for="additionalaccommodation-both">Both</label>
                    <label id="additionalaccommodationMsg">&nbsp;&nbsp;</label>
                </div>
            </div> 
        </div>
    
                    
            <div class="col-md-6 col-sm-12  mb-lg-0 pt-4" id="accompanying-opt">
                <div class="input-block">
                    <label class="form-check-label pb-3 pr-4">Do you want an accompanying person's registration? <span class="error">*</span></label><br/>
                    <div class="custom-control custom-radio custom-control-inline accompanying">
                        <input type="radio" value="acocompany_yes" id="acocompany_yes" name="accompanying" class="custom-control-input">
                        <label class="custom-control-label" for="acocompany_yes">Yes (50.00 USD)</label>
                    </div>
                    <div class="custom-control custom-radio custom-control-inline accompanying">
                        <input type="radio" value="acocompany-no" id="acocompany-no" name="accompanying" class="custom-control-input">
                        <label class="custom-control-label" for="acocompany-no">No</label>
                        <label id="accompanyingMsg">&nbsp;&nbsp;</label>
                    </div>
                </div> 
            </div>
        
                    
            <div class="col-md-6 col-sm-12  mb-lg-0 pt-4">
                <div class="input-block">
                    <label class="form-check-label pb-3 pr-4">Do you want to register for a pre-conference workshop?</label><br/>
                    <div class="custom-control custom-radio custom-control-inline prequestionConferenceWorkshop">
                        <input type="radio" value="prequestionConferenceWorkshop_yes" id="prequestionConferenceWorkshop_yes" name="prequestionConferenceWorkshop" class="custom-control-input">
                        <label class="custom-control-label" for="prequestionConferenceWorkshop_yes">Yes</label>
                    </div>
                    <div class="custom-control custom-radio custom-control-inline prequestionConferenceWorkshop">
                        <input type="radio" value="prequestionConferenceWorkshop_no" id="prequestionConferenceWorkshop_no" name="prequestionConferenceWorkshop" class="custom-control-input">
                        <label class="custom-control-label" for="prequestionConferenceWorkshop_no">No</label>
                        <label id="prequestionConferenceWorkshopMsg">&nbsp;&nbsp;</label>
                    </div>
                </div> 
            </div>
        
                    </div>
                    
            <div style="display:none" id="prequestionConferenceWorkshop-opt">
            <legend>Preconference Workshops</legend>
            <div class="form-group row">
                <div class="col-md-6 col-sm-12  mb-lg-0 pt-4" class="preconference-timeslot">
                    <label class="form-check-label pb-3 pr-4"><strong>Please select the workshop in the morning slot 9:00am - 12:00pm. The workshop fee is <span class="badge badge-pill badge-primary zoom-in-zoom-out">FREE</span></strong></label><br/>
                    <span id="preference_workshop_morningMsg"></span>
                    <div class="pb-3 custom-control custom-radio preference_workshop_morning">
                        <input type="radio" value="Workshop 1" id="morning-workshop1" name="preference_workshop_morning" class="custom-control-input">
                        <label id="preference_workshop_morningMsg" class="custom-control-label" for="morning-workshop1"><strong>Workshop 1</strong> - “Relevance of Entrustable Professional Activities (EPAs) in Dental Education: Developing the Essentials” by Prof Dr. Lin Liang Seow and A/P Dr. Sivakumar Arunachalam</label>
                    </div>
                    <div class="pb-3 custom-control custom-radio preference_workshop_morning">
                        <input type="radio" value="Workshop 2" id="morning-workshop2" name="preference_workshop_morning" class="custom-control-input">
                        <label style="word-spacing:-1px" class="custom-control-label" for="morning-workshop2"><strong>Workshop 2</strong> - “Special Care Dentistry in the undergraduate dental curriculum” by Prof. Emeritus Raman Bedi and A/P Dr. Jacob John</label>
                    </div>
                    <div class="custom-control custom-radio preference_workshop_morning">
                        <input type="radio" value="Workshop 3" id="morning-workshop3" name="preference_workshop_morning" class="custom-control-input">
                        <label class="custom-control-label" for="morning-workshop3"><strong>Workshop 3</strong> - “Designing Higher Order Questions to assess Clinical Reasoning Skills” by Prof. Toh Chooi Gait</label>
                        <label style="display:none" id="clear_morning_workshop"><a href="javascript:;">Clear your choice</a></label>
                    </div>
                    
                </div>
                
                <div class="col-md-6 col-sm-12  mb-lg-0 pt-4" class="preconference-timeslot">
                    <label class="form-check-label pb-3 pr-4"><strong>Please select the workshop in the afternoon slot 1:00pm - 4:00pm. The workshop fee is <span class="badge badge-pill badge-primary zoom-in-zoom-out">FREE</span></strong></label><br/>
                    <span id="preference_workshop_afternoonMsg"></span>
                    <div class="pb-3 custom-control custom-radio preference_workshop_afternoon">
                        <input type="radio" value="Workshop 4" id="afternoon-workshop4" name="preference_workshop_afternoon" class="custom-control-input">
                        <label class="custom-control-label" for="afternoon-workshop4"><strong>Workshop 4</strong> - “Systematic reviews and meta-analysis” by A/P Dr. Akhilanand Chaurasia</label>
                    </div>
                    <div class="pb-3 custom-control custom-radio preference_workshop_afternoon">
                        <input type="radio" value="Workshop 5" id="afternoon-workshop5" name="preference_workshop_afternoon" class="custom-control-input">
                        <label class="custom-control-label" for="afternoon-workshop5"><strong>Workshop 5</strong> - “Training Dental Students and Dentists on Early Detection of Oral Cancer using OralDETECT training programme” by Prof. Rosnah Zain and A/P Dr. Anand Ramanathan</label>
                    </div>
                    <div class="custom-control custom-radio preference_workshop_afternoon">
                        <input type="radio" value="Workshop 6" id="afternoon-workshop6" name="preference_workshop_afternoon" class="custom-control-input">
                        <label class="custom-control-label" for="afternoon-workshop6"><strong>Workshop 6</strong> - “Mirror, Mirror on the Wall... A Tale of Reflective Learning for Students and Educators” by A/P Wong Mun Loke</label><br/>
                        <label style="display:none" id="clear_afternoon_workshop"><a href="javascript:;">Clear your choice</a></label>
                    </div>
                </div>
            </div>
            </div>
        
                    
        <legend>Payment Details</legend>
        <div class="form-group row">
            <div class="col-md-12 col-sm-12  mb-lg-0 pt-4 text-center" id="paymentdetial-des">
                    To complete your registration process, kindly deposit the <strong>total amount <label class="total-amount"></label></strong> to the below mentioned account and attach the receipt for verification.
            </div>
        </div>
        <div class="form-group row">
            
                <div class="col-md-5 col-sm-12  mb-lg-0 border-success pt-4">
                    <div style="line-height:2">
                        <label><strong>Account receiver:</strong></label><br/>
                        <u>Beneficiary Name</u>: UNIVERSITY OF PUTHISASTRA CO LTD<br/>
                        <u>Beneficiary Address</u>: #55, Str 180-184 Sangkat Boeung Raing, Khan Daun Penh, Phnom Penh<br/>
                        <u>Beneficiary Account Number</u>: 001712925<br/>
                        <u>Beneficiary Bank Name</u>: ADVANCED BANK OF ASIA LIMITED<br/>
                        <u>Beneficiary Bank Address</u>: No 148 Preah Sihanouk Blvd, Phnom Penh, Cambodia<br/>
                        <u>Beneficiary Bank SWIFT Code</u>: ABAAKHPP
                    </div>
                </div> 
                <div class=" col-md-2 sep d-none d-lg-flex">
                    <span class="sepText mt-4"></span>
                </div>
                <div class="col-md-5 col-sm-12 pt-4">
                    <label class="pb-2"><strong>Account transfer:</strong></label>
                    <input type="text" class="form-control" name="bank_name" id="bank_name" placeholder="Bank name *" aria-label="Bank name *"><br/>
                    <input type="text" class="form-control" name="bank_account_name" id="bank_account_name" placeholder="Bank account name *" aria-label="Bank account name *"><br/>
                    <input type="number" class="form-control" name="bank_account_number" id="bank_account_number" placeholder="Bank account number *" aria-label="Bank account number *"><br/>
                    <input readonly type="text" id="transaction_date" name="transaction_date" class="form-control" placeholder="Transaction date *"><br/>
                    <input type="text" class="form-control" name="transaction_reference_number" id="transaction_reference_number" placeholder="Reference #" aria-label="Bank account name *"><br/>
                    <label for="cv_attachedment" class="form-label">Please attach your payment receipts here.<br/><small>(File types: .pdf or image/*, Maximum size 4MB)</small></label>
                    <input class="form-control" name="cv_attachedment" id="cv_attachedment" type="file">
                    <div class="error-message file_upload"></div><br/>
                </div>
                

            
        </div>   
        
                    
        <legend>T&C's</legend>

        <input placeholder="Accomdation_Price" type="hidden" name="accomdation_price_hidden" id="accomdation_price_hidden">
        
        <input placeholder="package_price_hidden" type="hidden" name="package_price_hidden" id="package_price_hidden">

        <input placeholder="Accompanying_price" type="hidden" name="accompanying_price_hidden_hidden" id="accompanying_price_hidden_hidden">
        <input placeholder="Pre_conf_morning_Price" type="hidden" name="pre_conference_morning_price_hidden" id="pre_conference_morning_price_hidden">
        <input placeholder="Pre_conf_afternoon_Price" type="hidden" name="pre_conference_afternoon_price_hidden" id="pre_conference_afternoon_price_hidden">
        

        <div class="form-check text-center pt-4">
            <input class="form-check-input custom-larger" type="checkbox" value="1" name="tnc" id="tncfield" require>
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                By ticking the box you have accepted our <a target="_blank" href="https://www.puthisastra.edu.kh/seaade/terms-and-conditions/">Terms & Conditions</a>
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            <div class="col-md-12 col-sm-12 text-center pt-4 pb-5">
                <input type="hidden" id="mwp-dropform-nonce" name="mwp-dropform-nonce" value="b35dfbea6e">
                <input type="submit" name="submit_seaade_application" class="submit_seaade btn btn-primary" value="Apply Now"/>
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