Join Club Centaur - Rémy Martin

<article class="lite"> <section> <form id="signUp" class="padded" action="/embed" method="POST"> <a href="/log-in" class="button btnAuto"> ALREADY A MEMBER? LOG IN </a> <input type="hidden" name="referredbyemail__c" value=""> <input type="hidden" name="data_source_details__c" value=""> <div class="icon"></div> <h1 class="padded">WELCOME TO THE CLUB</h1> <p class="remy slim">Join Rémy Martin Club Centaur for special offers, exclusive invitations to events, inspiring stories about Rémy Martin and cognac, cocktail recipes curated by Rémy Martin mixologists and more.</p>   <div class="padded"> <div class="fancy-question on"> <p class="fancy">What is your first name?</p> <input required="" class="fancy slimmer fancyInput" id="FirstName" type="text" name="FirstName" value=""> </div> <div class="fancy-question on"> <p class="fancy">What is your last name?</p> <input required="" class="fancy slimmer fancyInput" id="LastName" type="text" name="LastName" value=""> </div> <div class="fancy-question on"> <p class="fancy">When is your birthday?</p> <input required="" class="fancy slimmer fancyInput" id="formattedBday" type="text" name="Birthdate" style="-webkit-padding-start: 3em;" value="" placeholder="mm/dd/yyyy"> </div> <div class="fancy-question on"> <p class="fancy">What is your email?</p> <input required="" class="fancy slimmer fancyInput" id="email" type="email" name="Email" value=""> </div> <div class="fancy-question on"> <p class="fancy">Confirm Your Email Address</p> <input required="" class="fancy slimmer fancyInput" id="EmailConfirm" type="email" name="EmailConfirm" value=""> </div> <div class="fancy-question on"> <p class="fancy">What is your zip code?</p> <input required="" class="fancy slimmer fancyInput" id="PostalCode" type="text" name="PostalCode" value=""> </div> <div class="fancy-question on"> <p class="fancy">What password will you use?</p> <input autocomplete="new-password" required="" class="fancy slimmer fancyInput" id="password" type="password" name="rmus_Password__c"> </div> <div class="fancy-question on"> <p class="fancy">Confirm password</p> <input required="" class="fancy slimmer fancyInput" id="password_confirm" type="password" name="rmus_Password__cc"> </div> <p id="errorMessages" style="text-align: center; color: #DA0000;"> </p> <p id="errorMessages" style="text-align: center; color: #DA0000; margin-bottom: 30px;"></p> </div> <button id="btnsubmit" class="button btn-submit" type="button">SUBMIT</button> <div style="margin-top:4em;"> <label class="legal slimmer">By clicking submit you are agreeing to the Terms & Conditions, Privacy Policy and receiving future communications from Rémy Martin.</label> </div> </form> </section> </article>

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