  
            <form id="redemptionGroupNomination" method="post" action="" name="redemption_group_nomination" class="inner-form" enctype="multipart/form-data" onsubmit="return validateForm();">
                        <div class="col-md-12 col-lg-12 col-sm-12">
                        	                            <div class="thankyou" style=""></div>
                        </div>
                        <div class="rs_miles_form">
                                <div class="col-md-10 col-lg-10 col-sm-10">
                                    <p>This form can be used to nominate up to 5 individuals for whom can redeem your Royal Skies miles for flight and upgrade rewards.</p>
                                    <h3 class="first_head">Member Details</h3>
                                    <div class="form-group">
                                        <label for="">Royal Skies Membership No.</label> <span class="err_ast">*</span>
                                        <div class="input-group">
                                            <input class="form__text form-control" id="rs_member_no" name="rs_member_no" type="text" required="" autocomplete="off" value="">
                                            <span id="spnmemberno"></span>
                                        </div>
                                   </div>
                                    <div class="form-group">
                                        <label for="">Name as Printed in Passport</label> <span class="err_ast">*</span>
                                        <div class="input-group">
                                            <input class="form__text form-control" id="member_update_name" name="member_update_name" type="text" required="" autocomplete="off" value="">
                                             <span id="spnname"></span>
                                        </div>
                                   </div>
                                    <!--<div class="form-group">
                                        <label for="File">Choose File:</label> <span class="err_ast">*</span>
                                        <input type="file" id="name_passport" class="name_passport" name="name_passport" accept="image/png, image/jpeg" />
                                        <label for="name_passport">Upload a Passport Copy</label>
                                    </div>-->
                                    <div class="form-group">
                                        <label for="">Telephone (Eg: 61412341234)</label> <span class="err_ast">*</span>
                                        <div class="input-group">
                                            <input class="form__text form-control" id="member_ext_phone" name="member_ext_phone" type="tel" required="" autocomplete="off" value="">
                                             <span id="spnPhoneStatus"></span>
                                        </div>
                                    </div>
                                    <div class="form-group">
                                        <label for="">Email Address</label> <span class="err_ast">*</span>
                                        <div class="input-group">
                                            <input class="form__text form-control" id="member_update_email" name="member_update_email" type="email" required="" autocomplete="off" value="">
                                        </div>
                                    </div>
                                </div>
                                <div class="col-md-2 col-lg-2 col-sm-2"></div>
                                <div class="col-md-10 col-lg-10 col-sm-10 nominee_table">
                                    <h3>Redemption Group Nomination</h3>
                                    <p>I hereby authorize Royal Brunei Airlines to issue free awards (subject to the Terms and Conditions of the programme) to the following nominee(s) in exchange for Royal Skies Miles.</p>
                                    <p>I understand that the list of nominees named here will override any previous list of nominees (if any) that I have submitted. Below are the nominee(s) whom I authorize to make bookings and collect redemption tickets from Royal Brunei Customer Service Centre for themselves and on my behalf.</p>
                                    <div class="table-responsivee">

                                    	<div class="row hidden-xs">
	                                    		<div class="col-md-1">
                                                    <div class="form-group">
                                                        <label for="">#</label>
                                                    </div>
	                                            </div>
                                                <div class="col-md-3">
                                                    <div class="form-group">
                                                        <label for="">Name Of Authorized Nominees</label>
                                                    </div>
                                                </div>
                                                <div class="col-md-5">
                                                    <div class="form-group">
                                                        <label for="" class="birth_date_label">Date of Birth</label> 
                                                    </div>
                                                </div>
                                                <div class="col-md-3">
                                                   <div class="form-group">
                                                        <label for="">Membership No.</label>
                                                    </div>
                                                </div>
                                            </div>


                                            <div class="row">
                                            	<div class="col-md-1 hidden-xs">
                                                    <div class="form-group">
                                                        <div class="input-group">
                                                            1
                                                            <span id="spanfamname"></span>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="col-md-3">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Name Of Authorized Nominees</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="nominee1" name="nominee1" type="text" required value="">
                                                            <span id="spanfamname"></span>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="col-md-5">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Date of Birth</label>
                                                         <select id="birth_date11" name="birth_date1" tabindex="-1" title="" class="required form-control" >
                                                              <option value="">--Select--</option>
                                                             
                                                            <option value="01">01</option>  
                                                             
                                                            <option value="02">02</option>  
                                                             
                                                            <option value="03">03</option>  
                                                             
                                                            <option value="04">04</option>  
                                                             
                                                            <option value="05">05</option>  
                                                             
                                                            <option value="06">06</option>  
                                                             
                                                            <option value="07">07</option>  
                                                             
                                                            <option value="08">08</option>  
                                                             
                                                            <option value="09">09</option>  
                                                             
                                                            <option value="10">10</option>  
                                                             
                                                            <option value="11">11</option>  
                                                             
                                                            <option value="12">12</option>  
                                                             
                                                            <option value="13">13</option>  
                                                             
                                                            <option value="14">14</option>  
                                                             
                                                            <option value="15">15</option>  
                                                             
                                                            <option value="16">16</option>  
                                                             
                                                            <option value="17">17</option>  
                                                             
                                                            <option value="18">18</option>  
                                                             
                                                            <option value="19">19</option>  
                                                             
                                                            <option value="20">20</option>  
                                                             
                                                            <option value="21">21</option>  
                                                             
                                                            <option value="22">22</option>  
                                                             
                                                            <option value="23">23</option>  
                                                             
                                                            <option value="24">24</option>  
                                                             
                                                            <option value="25">25</option>  
                                                             
                                                            <option value="26">26</option>  
                                                             
                                                            <option value="27">27</option>  
                                                             
                                                            <option value="28">28</option>  
                                                             
                                                            <option value="29">29</option>  
                                                             
                                                            <option value="30">30</option>  
                                                             
                                                            <option value="31">31</option>  
                                                                                                                     </select>
                                                         <select id="birth_month1" name="birth_month1" tabindex="-1" title="" class="required form-control" >
                                                                <option value="">--Select--</option>
                                                                <option value="Jan">Jan</option>
                                                                 <option value="Feb">Feb</option> 
                                                                 <option value="Mar">Mar</option> 
                                                                 <option value="Apr">Apr</option> 
                                                                 <option value="May">May</option>
                                                                 <option value="Jun">Jun</option> 
                                                                 <option value="Jul">Jul</option> 
                                                                 <option value="Aug">Aug</option>
                                                                 <option value="Sep">Sep</option> 
                                                                 <option value="Oct">Oct</option> 
                                                                 <option value="Nov">Nov</option> 
                                                                 <option value="Dec">Dec</option> 
                                                            </select>
                                                        <select id="birth_year1" name="birth_year1" tabindex="-1" title="" class="required form-control">
                                                                 <option value="">--Select--</option>
                                                                 
                                                                <option value="1930">1930</option>  
                                                                 
                                                                <option value="1931">1931</option>  
                                                                 
                                                                <option value="1932">1932</option>  
                                                                 
                                                                <option value="1933">1933</option>  
                                                                 
                                                                <option value="1934">1934</option>  
                                                                 
                                                                <option value="1935">1935</option>  
                                                                 
                                                                <option value="1936">1936</option>  
                                                                 
                                                                <option value="1937">1937</option>  
                                                                 
                                                                <option value="1938">1938</option>  
                                                                 
                                                                <option value="1939">1939</option>  
                                                                 
                                                                <option value="1940">1940</option>  
                                                                 
                                                                <option value="1941">1941</option>  
                                                                 
                                                                <option value="1942">1942</option>  
                                                                 
                                                                <option value="1943">1943</option>  
                                                                 
                                                                <option value="1944">1944</option>  
                                                                 
                                                                <option value="1945">1945</option>  
                                                                 
                                                                <option value="1946">1946</option>  
                                                                 
                                                                <option value="1947">1947</option>  
                                                                 
                                                                <option value="1948">1948</option>  
                                                                 
                                                                <option value="1949">1949</option>  
                                                                 
                                                                <option value="1950">1950</option>  
                                                                 
                                                                <option value="1951">1951</option>  
                                                                 
                                                                <option value="1952">1952</option>  
                                                                 
                                                                <option value="1953">1953</option>  
                                                                 
                                                                <option value="1954">1954</option>  
                                                                 
                                                                <option value="1955">1955</option>  
                                                                 
                                                                <option value="1956">1956</option>  
                                                                 
                                                                <option value="1957">1957</option>  
                                                                 
                                                                <option value="1958">1958</option>  
                                                                 
                                                                <option value="1959">1959</option>  
                                                                 
                                                                <option value="1960">1960</option>  
                                                                 
                                                                <option value="1961">1961</option>  
                                                                 
                                                                <option value="1962">1962</option>  
                                                                 
                                                                <option value="1963">1963</option>  
                                                                 
                                                                <option value="1964">1964</option>  
                                                                 
                                                                <option value="1965">1965</option>  
                                                                 
                                                                <option value="1966">1966</option>  
                                                                 
                                                                <option value="1967">1967</option>  
                                                                 
                                                                <option value="1968">1968</option>  
                                                                 
                                                                <option value="1969">1969</option>  
                                                                 
                                                                <option value="1970">1970</option>  
                                                                 
                                                                <option value="1971">1971</option>  
                                                                 
                                                                <option value="1972">1972</option>  
                                                                 
                                                                <option value="1973">1973</option>  
                                                                 
                                                                <option value="1974">1974</option>  
                                                                 
                                                                <option value="1975">1975</option>  
                                                                 
                                                                <option value="1976">1976</option>  
                                                                 
                                                                <option value="1977">1977</option>  
                                                                 
                                                                <option value="1978">1978</option>  
                                                                 
                                                                <option value="1979">1979</option>  
                                                                 
                                                                <option value="1980">1980</option>  
                                                                 
                                                                <option value="1981">1981</option>  
                                                                 
                                                                <option value="1982">1982</option>  
                                                                 
                                                                <option value="1983">1983</option>  
                                                                 
                                                                <option value="1984">1984</option>  
                                                                 
                                                                <option value="1985">1985</option>  
                                                                 
                                                                <option value="1986">1986</option>  
                                                                 
                                                                <option value="1987">1987</option>  
                                                                 
                                                                <option value="1988">1988</option>  
                                                                 
                                                                <option value="1989">1989</option>  
                                                                 
                                                                <option value="1990">1990</option>  
                                                                 
                                                                <option value="1991">1991</option>  
                                                                 
                                                                <option value="1992">1992</option>  
                                                                 
                                                                <option value="1993">1993</option>  
                                                                 
                                                                <option value="1994">1994</option>  
                                                                 
                                                                <option value="1995">1995</option>  
                                                                 
                                                                <option value="1996">1996</option>  
                                                                 
                                                                <option value="1997">1997</option>  
                                                                 
                                                                <option value="1998">1998</option>  
                                                                 
                                                                <option value="1999">1999</option>  
                                                                 
                                                                <option value="2000">2000</option>  
                                                                 
                                                                <option value="2001">2001</option>  
                                                                 
                                                                <option value="2002">2002</option>  
                                                                 
                                                                <option value="2003">2003</option>  
                                                                 
                                                                <option value="2004">2004</option>  
                                                                 
                                                                <option value="2005">2005</option>  
                                                                 
                                                                <option value="2006">2006</option>  
                                                                 
                                                                <option value="2007">2007</option>  
                                                                 
                                                                <option value="2008">2008</option>  
                                                                 
                                                                <option value="2009">2009</option>  
                                                                 
                                                                <option value="2010">2010</option>  
                                                                 
                                                                <option value="2011">2011</option>  
                                                                 
                                                                <option value="2012">2012</option>  
                                                                 
                                                                <option value="2013">2013</option>  
                                                                 
                                                                <option value="2014">2014</option>  
                                                                 
                                                                <option value="2015">2015</option>  
                                                                 
                                                                <option value="2016">2016</option>  
                                                                 
                                                                <option value="2017">2017</option>  
                                                                 
                                                                <option value="2018">2018</option>  
                                                                 
                                                                <option value="2019">2019</option>  
                                                                                                                         </select>
                                                    </div>
                                                </div>                           
                                                <div class="col-md-3">
                                                   <div class="form-group">
                                                   	<label for="" class="visible-xs">Membership No</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="membership_no1" name="membership_no1" type="text" required value="">
                                                            <span id="spanmemberno"></span>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="row">
                                            	<div class="col-md-1 hidden-xs">
                                                    <div class="form-group">
                                                        2
                                                    </div>
                                                </div>
                                                <div class="col-md-3">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Name Of Authorized Nominees</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="nominee2" name="nominee2" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                                 <div class="col-md-5">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Date of Birth</label>
                                                         <select id="birth_date2" name="birth_date2" tabindex="-1" title="" class="form-control">
                                                              <option value="">--Select--</option>
                                                             
                                                            <option value="01">01</option>  
                                                             
                                                            <option value="02">02</option>  
                                                             
                                                            <option value="03">03</option>  
                                                             
                                                            <option value="04">04</option>  
                                                             
                                                            <option value="05">05</option>  
                                                             
                                                            <option value="06">06</option>  
                                                             
                                                            <option value="07">07</option>  
                                                             
                                                            <option value="08">08</option>  
                                                             
                                                            <option value="09">09</option>  
                                                             
                                                            <option value="10">10</option>  
                                                             
                                                            <option value="11">11</option>  
                                                             
                                                            <option value="12">12</option>  
                                                             
                                                            <option value="13">13</option>  
                                                             
                                                            <option value="14">14</option>  
                                                             
                                                            <option value="15">15</option>  
                                                             
                                                            <option value="16">16</option>  
                                                             
                                                            <option value="17">17</option>  
                                                             
                                                            <option value="18">18</option>  
                                                             
                                                            <option value="19">19</option>  
                                                             
                                                            <option value="20">20</option>  
                                                             
                                                            <option value="21">21</option>  
                                                             
                                                            <option value="22">22</option>  
                                                             
                                                            <option value="23">23</option>  
                                                             
                                                            <option value="24">24</option>  
                                                             
                                                            <option value="25">25</option>  
                                                             
                                                            <option value="26">26</option>  
                                                             
                                                            <option value="27">27</option>  
                                                             
                                                            <option value="28">28</option>  
                                                             
                                                            <option value="29">29</option>  
                                                             
                                                            <option value="30">30</option>  
                                                             
                                                            <option value="31">31</option>  
                                                                                                                     </select>
                                            
                                                     <select id="birth_month2" name="birth_month2" tabindex="-1" title="" class="form-control">
                                                        <option value="">--Select--</option>
                                                        <option value="Jan">Jan</option>
                                                         <option value="Feb">Feb</option> 
                                                         <option value="Mar">Mar</option> 
                                                         <option value="Apr">Apr</option> 
                                                         <option value="May">May</option>
                                                         <option value="Jun">Jun</option> 
                                                         <option value="Jul">Jul</option> 
                                                         <option value="Aug">Aug</option>
                                                         <option value="Sep">Sep</option> 
                                                         <option value="Oct">Oct</option> 
                                                         <option value="Nov">Nov</option> 
                                                         <option value="Dec">Dec</option> 
                                                    </select>
                                                    
                                                     <select id="birth_year2" name="birth_year2" tabindex="-1" title="" class="form-control">
                                                         <option value="">--Select--</option>
                                                         
                                                        <option value="1930">1930</option>  
                                                         
                                                        <option value="1931">1931</option>  
                                                         
                                                        <option value="1932">1932</option>  
                                                         
                                                        <option value="1933">1933</option>  
                                                         
                                                        <option value="1934">1934</option>  
                                                         
                                                        <option value="1935">1935</option>  
                                                         
                                                        <option value="1936">1936</option>  
                                                         
                                                        <option value="1937">1937</option>  
                                                         
                                                        <option value="1938">1938</option>  
                                                         
                                                        <option value="1939">1939</option>  
                                                         
                                                        <option value="1940">1940</option>  
                                                         
                                                        <option value="1941">1941</option>  
                                                         
                                                        <option value="1942">1942</option>  
                                                         
                                                        <option value="1943">1943</option>  
                                                         
                                                        <option value="1944">1944</option>  
                                                         
                                                        <option value="1945">1945</option>  
                                                         
                                                        <option value="1946">1946</option>  
                                                         
                                                        <option value="1947">1947</option>  
                                                         
                                                        <option value="1948">1948</option>  
                                                         
                                                        <option value="1949">1949</option>  
                                                         
                                                        <option value="1950">1950</option>  
                                                         
                                                        <option value="1951">1951</option>  
                                                         
                                                        <option value="1952">1952</option>  
                                                         
                                                        <option value="1953">1953</option>  
                                                         
                                                        <option value="1954">1954</option>  
                                                         
                                                        <option value="1955">1955</option>  
                                                         
                                                        <option value="1956">1956</option>  
                                                         
                                                        <option value="1957">1957</option>  
                                                         
                                                        <option value="1958">1958</option>  
                                                         
                                                        <option value="1959">1959</option>  
                                                         
                                                        <option value="1960">1960</option>  
                                                         
                                                        <option value="1961">1961</option>  
                                                         
                                                        <option value="1962">1962</option>  
                                                         
                                                        <option value="1963">1963</option>  
                                                         
                                                        <option value="1964">1964</option>  
                                                         
                                                        <option value="1965">1965</option>  
                                                         
                                                        <option value="1966">1966</option>  
                                                         
                                                        <option value="1967">1967</option>  
                                                         
                                                        <option value="1968">1968</option>  
                                                         
                                                        <option value="1969">1969</option>  
                                                         
                                                        <option value="1970">1970</option>  
                                                         
                                                        <option value="1971">1971</option>  
                                                         
                                                        <option value="1972">1972</option>  
                                                         
                                                        <option value="1973">1973</option>  
                                                         
                                                        <option value="1974">1974</option>  
                                                         
                                                        <option value="1975">1975</option>  
                                                         
                                                        <option value="1976">1976</option>  
                                                         
                                                        <option value="1977">1977</option>  
                                                         
                                                        <option value="1978">1978</option>  
                                                         
                                                        <option value="1979">1979</option>  
                                                         
                                                        <option value="1980">1980</option>  
                                                         
                                                        <option value="1981">1981</option>  
                                                         
                                                        <option value="1982">1982</option>  
                                                         
                                                        <option value="1983">1983</option>  
                                                         
                                                        <option value="1984">1984</option>  
                                                         
                                                        <option value="1985">1985</option>  
                                                         
                                                        <option value="1986">1986</option>  
                                                         
                                                        <option value="1987">1987</option>  
                                                         
                                                        <option value="1988">1988</option>  
                                                         
                                                        <option value="1989">1989</option>  
                                                         
                                                        <option value="1990">1990</option>  
                                                         
                                                        <option value="1991">1991</option>  
                                                         
                                                        <option value="1992">1992</option>  
                                                         
                                                        <option value="1993">1993</option>  
                                                         
                                                        <option value="1994">1994</option>  
                                                         
                                                        <option value="1995">1995</option>  
                                                         
                                                        <option value="1996">1996</option>  
                                                         
                                                        <option value="1997">1997</option>  
                                                         
                                                        <option value="1998">1998</option>  
                                                         
                                                        <option value="1999">1999</option>  
                                                         
                                                        <option value="2000">2000</option>  
                                                         
                                                        <option value="2001">2001</option>  
                                                         
                                                        <option value="2002">2002</option>  
                                                         
                                                        <option value="2003">2003</option>  
                                                         
                                                        <option value="2004">2004</option>  
                                                         
                                                        <option value="2005">2005</option>  
                                                         
                                                        <option value="2006">2006</option>  
                                                         
                                                        <option value="2007">2007</option>  
                                                         
                                                        <option value="2008">2008</option>  
                                                         
                                                        <option value="2009">2009</option>  
                                                         
                                                        <option value="2010">2010</option>  
                                                         
                                                        <option value="2011">2011</option>  
                                                         
                                                        <option value="2012">2012</option>  
                                                         
                                                        <option value="2013">2013</option>  
                                                         
                                                        <option value="2014">2014</option>  
                                                         
                                                        <option value="2015">2015</option>  
                                                         
                                                        <option value="2016">2016</option>  
                                                         
                                                        <option value="2017">2017</option>  
                                                         
                                                        <option value="2018">2018</option>  
                                                         
                                                        <option value="2019">2019</option>  
                                                                                                             </select>
                                                    </div>
                                                 </div>
                                                 <div class="col-md-3">
                                                   <div class="form-group">
                                                   	<label for="" class="visible-xs">Membership No</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="membership_no2" name="membership_no2" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="row">
                                            	<div class="col-md-1 hidden-xs">
                                                    <div class="form-group">
                                                        3
                                                    </div>
                                                </div>
                                                 <div class="col-md-3">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Name Of Authorized Nominees</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="nominee3" name="nominee3" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                                 <div class="col-md-5">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Date of Birth</label>
                                                             <select id="birth_date3" name="birth_date3" tabindex="-1" title="" class="form-control">
                                                                  <option value="">--Select--</option>
                                                                 
                                                                <option value="01">01</option>  
                                                                 
                                                                <option value="02">02</option>  
                                                                 
                                                                <option value="03">03</option>  
                                                                 
                                                                <option value="04">04</option>  
                                                                 
                                                                <option value="05">05</option>  
                                                                 
                                                                <option value="06">06</option>  
                                                                 
                                                                <option value="07">07</option>  
                                                                 
                                                                <option value="08">08</option>  
                                                                 
                                                                <option value="09">09</option>  
                                                                 
                                                                <option value="10">10</option>  
                                                                 
                                                                <option value="11">11</option>  
                                                                 
                                                                <option value="12">12</option>  
                                                                 
                                                                <option value="13">13</option>  
                                                                 
                                                                <option value="14">14</option>  
                                                                 
                                                                <option value="15">15</option>  
                                                                 
                                                                <option value="16">16</option>  
                                                                 
                                                                <option value="17">17</option>  
                                                                 
                                                                <option value="18">18</option>  
                                                                 
                                                                <option value="19">19</option>  
                                                                 
                                                                <option value="20">20</option>  
                                                                 
                                                                <option value="21">21</option>  
                                                                 
                                                                <option value="22">22</option>  
                                                                 
                                                                <option value="23">23</option>  
                                                                 
                                                                <option value="24">24</option>  
                                                                 
                                                                <option value="25">25</option>  
                                                                 
                                                                <option value="26">26</option>  
                                                                 
                                                                <option value="27">27</option>  
                                                                 
                                                                <option value="28">28</option>  
                                                                 
                                                                <option value="29">29</option>  
                                                                 
                                                                <option value="30">30</option>  
                                                                 
                                                                <option value="31">31</option>  
                                                                                                                             </select>
                                                            
                                                             <select id="birth_month3" name="birth_month3" tabindex="-1" title="" class="form-control">
                                                                <option value="">--Select--</option>
                                                                <option value="Jan">Jan</option>
                                                                 <option value="Feb">Feb</option> 
                                                                 <option value="Mar">Mar</option> 
                                                                 <option value="Apr">Apr</option> 
                                                                 <option value="May">May</option>
                                                                 <option value="Jun">Jun</option> 
                                                                 <option value="Jul">Jul</option> 
                                                                 <option value="Aug">Aug</option>
                                                                 <option value="Sep">Sep</option> 
                                                                 <option value="Oct">Oct</option> 
                                                                 <option value="Nov">Nov</option> 
                                                                 <option value="Dec">Dec</option> 
                                                            </select>
                                                             <select id="birth_year3" name="birth_year3" tabindex="-1" title="" class="form-control">
                                                                 <option value="">--Select--</option>
                                                                 
                                                                <option value="1930">1930</option>  
                                                                 
                                                                <option value="1931">1931</option>  
                                                                 
                                                                <option value="1932">1932</option>  
                                                                 
                                                                <option value="1933">1933</option>  
                                                                 
                                                                <option value="1934">1934</option>  
                                                                 
                                                                <option value="1935">1935</option>  
                                                                 
                                                                <option value="1936">1936</option>  
                                                                 
                                                                <option value="1937">1937</option>  
                                                                 
                                                                <option value="1938">1938</option>  
                                                                 
                                                                <option value="1939">1939</option>  
                                                                 
                                                                <option value="1940">1940</option>  
                                                                 
                                                                <option value="1941">1941</option>  
                                                                 
                                                                <option value="1942">1942</option>  
                                                                 
                                                                <option value="1943">1943</option>  
                                                                 
                                                                <option value="1944">1944</option>  
                                                                 
                                                                <option value="1945">1945</option>  
                                                                 
                                                                <option value="1946">1946</option>  
                                                                 
                                                                <option value="1947">1947</option>  
                                                                 
                                                                <option value="1948">1948</option>  
                                                                 
                                                                <option value="1949">1949</option>  
                                                                 
                                                                <option value="1950">1950</option>  
                                                                 
                                                                <option value="1951">1951</option>  
                                                                 
                                                                <option value="1952">1952</option>  
                                                                 
                                                                <option value="1953">1953</option>  
                                                                 
                                                                <option value="1954">1954</option>  
                                                                 
                                                                <option value="1955">1955</option>  
                                                                 
                                                                <option value="1956">1956</option>  
                                                                 
                                                                <option value="1957">1957</option>  
                                                                 
                                                                <option value="1958">1958</option>  
                                                                 
                                                                <option value="1959">1959</option>  
                                                                 
                                                                <option value="1960">1960</option>  
                                                                 
                                                                <option value="1961">1961</option>  
                                                                 
                                                                <option value="1962">1962</option>  
                                                                 
                                                                <option value="1963">1963</option>  
                                                                 
                                                                <option value="1964">1964</option>  
                                                                 
                                                                <option value="1965">1965</option>  
                                                                 
                                                                <option value="1966">1966</option>  
                                                                 
                                                                <option value="1967">1967</option>  
                                                                 
                                                                <option value="1968">1968</option>  
                                                                 
                                                                <option value="1969">1969</option>  
                                                                 
                                                                <option value="1970">1970</option>  
                                                                 
                                                                <option value="1971">1971</option>  
                                                                 
                                                                <option value="1972">1972</option>  
                                                                 
                                                                <option value="1973">1973</option>  
                                                                 
                                                                <option value="1974">1974</option>  
                                                                 
                                                                <option value="1975">1975</option>  
                                                                 
                                                                <option value="1976">1976</option>  
                                                                 
                                                                <option value="1977">1977</option>  
                                                                 
                                                                <option value="1978">1978</option>  
                                                                 
                                                                <option value="1979">1979</option>  
                                                                 
                                                                <option value="1980">1980</option>  
                                                                 
                                                                <option value="1981">1981</option>  
                                                                 
                                                                <option value="1982">1982</option>  
                                                                 
                                                                <option value="1983">1983</option>  
                                                                 
                                                                <option value="1984">1984</option>  
                                                                 
                                                                <option value="1985">1985</option>  
                                                                 
                                                                <option value="1986">1986</option>  
                                                                 
                                                                <option value="1987">1987</option>  
                                                                 
                                                                <option value="1988">1988</option>  
                                                                 
                                                                <option value="1989">1989</option>  
                                                                 
                                                                <option value="1990">1990</option>  
                                                                 
                                                                <option value="1991">1991</option>  
                                                                 
                                                                <option value="1992">1992</option>  
                                                                 
                                                                <option value="1993">1993</option>  
                                                                 
                                                                <option value="1994">1994</option>  
                                                                 
                                                                <option value="1995">1995</option>  
                                                                 
                                                                <option value="1996">1996</option>  
                                                                 
                                                                <option value="1997">1997</option>  
                                                                 
                                                                <option value="1998">1998</option>  
                                                                 
                                                                <option value="1999">1999</option>  
                                                                 
                                                                <option value="2000">2000</option>  
                                                                 
                                                                <option value="2001">2001</option>  
                                                                 
                                                                <option value="2002">2002</option>  
                                                                 
                                                                <option value="2003">2003</option>  
                                                                 
                                                                <option value="2004">2004</option>  
                                                                 
                                                                <option value="2005">2005</option>  
                                                                 
                                                                <option value="2006">2006</option>  
                                                                 
                                                                <option value="2007">2007</option>  
                                                                 
                                                                <option value="2008">2008</option>  
                                                                 
                                                                <option value="2009">2009</option>  
                                                                 
                                                                <option value="2010">2010</option>  
                                                                 
                                                                <option value="2011">2011</option>  
                                                                 
                                                                <option value="2012">2012</option>  
                                                                 
                                                                <option value="2013">2013</option>  
                                                                 
                                                                <option value="2014">2014</option>  
                                                                 
                                                                <option value="2015">2015</option>  
                                                                 
                                                                <option value="2016">2016</option>  
                                                                 
                                                                <option value="2017">2017</option>  
                                                                 
                                                                <option value="2018">2018</option>  
                                                                 
                                                                <option value="2019">2019</option>  
                                                                                                                             </select>
                                                    </div>
                                                 </div>
                                                 <div class="col-md-3">
                                                   <div class="form-group">
                                                   	<label for="" class="visible-xs">Membership No</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="membership_no3" name="membership_no3" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>          
                                            <div class="row">
                                            	<div class="col-md-1 hidden-xs">
                                                    <div class="form-group">
                                                        4
                                                    </div>
                                                </div>
                                                <div class="col-md-3">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Name Of Authorized Nominees</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="nominee4" name="nominee4" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                                 <div class="col-md-5">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Date of Birth</label>
                                                           <select id="birth_date4" name="birth_date4" tabindex="-1" title="" class="form-control">
                                                                  <option value="">--Select--</option>
                                                                 
                                                                <option value="01">01</option>  
                                                                 
                                                                <option value="02">02</option>  
                                                                 
                                                                <option value="03">03</option>  
                                                                 
                                                                <option value="04">04</option>  
                                                                 
                                                                <option value="05">05</option>  
                                                                 
                                                                <option value="06">06</option>  
                                                                 
                                                                <option value="07">07</option>  
                                                                 
                                                                <option value="08">08</option>  
                                                                 
                                                                <option value="09">09</option>  
                                                                 
                                                                <option value="10">10</option>  
                                                                 
                                                                <option value="11">11</option>  
                                                                 
                                                                <option value="12">12</option>  
                                                                 
                                                                <option value="13">13</option>  
                                                                 
                                                                <option value="14">14</option>  
                                                                 
                                                                <option value="15">15</option>  
                                                                 
                                                                <option value="16">16</option>  
                                                                 
                                                                <option value="17">17</option>  
                                                                 
                                                                <option value="18">18</option>  
                                                                 
                                                                <option value="19">19</option>  
                                                                 
                                                                <option value="20">20</option>  
                                                                 
                                                                <option value="21">21</option>  
                                                                 
                                                                <option value="22">22</option>  
                                                                 
                                                                <option value="23">23</option>  
                                                                 
                                                                <option value="24">24</option>  
                                                                 
                                                                <option value="25">25</option>  
                                                                 
                                                                <option value="26">26</option>  
                                                                 
                                                                <option value="27">27</option>  
                                                                 
                                                                <option value="28">28</option>  
                                                                 
                                                                <option value="29">29</option>  
                                                                 
                                                                <option value="30">30</option>  
                                                                 
                                                                <option value="31">31</option>  
                                                                                                                             </select>
                                                    
                                                             <select id="birth_month4" name="birth_month4" tabindex="-1" title="" class="form-control">
                                                                <option value="">--Select--</option>
                                                                <option value="Jan">Jan</option>
                                                                 <option value="Feb">Feb</option> 
                                                                 <option value="Mar">Mar</option> 
                                                                 <option value="Apr">Apr</option> 
                                                                 <option value="May">May</option>
                                                                 <option value="Jun">Jun</option> 
                                                                 <option value="Jul">Jul</option> 
                                                                 <option value="Aug">Aug</option>
                                                                 <option value="Sep">Sep</option> 
                                                                 <option value="Oct">Oct</option> 
                                                                 <option value="Nov">Nov</option> 
                                                                 <option value="Dec">Dec</option> 
                                                            </select>
                                                                                
                                                             <select id="birth_year4" name="birth_year4" tabindex="-1" title="" class="form-control">
                                                                 <option value="">--Select--</option>
                                                                 
                                                                <option value="1930">1930</option>  
                                                                 
                                                                <option value="1931">1931</option>  
                                                                 
                                                                <option value="1932">1932</option>  
                                                                 
                                                                <option value="1933">1933</option>  
                                                                 
                                                                <option value="1934">1934</option>  
                                                                 
                                                                <option value="1935">1935</option>  
                                                                 
                                                                <option value="1936">1936</option>  
                                                                 
                                                                <option value="1937">1937</option>  
                                                                 
                                                                <option value="1938">1938</option>  
                                                                 
                                                                <option value="1939">1939</option>  
                                                                 
                                                                <option value="1940">1940</option>  
                                                                 
                                                                <option value="1941">1941</option>  
                                                                 
                                                                <option value="1942">1942</option>  
                                                                 
                                                                <option value="1943">1943</option>  
                                                                 
                                                                <option value="1944">1944</option>  
                                                                 
                                                                <option value="1945">1945</option>  
                                                                 
                                                                <option value="1946">1946</option>  
                                                                 
                                                                <option value="1947">1947</option>  
                                                                 
                                                                <option value="1948">1948</option>  
                                                                 
                                                                <option value="1949">1949</option>  
                                                                 
                                                                <option value="1950">1950</option>  
                                                                 
                                                                <option value="1951">1951</option>  
                                                                 
                                                                <option value="1952">1952</option>  
                                                                 
                                                                <option value="1953">1953</option>  
                                                                 
                                                                <option value="1954">1954</option>  
                                                                 
                                                                <option value="1955">1955</option>  
                                                                 
                                                                <option value="1956">1956</option>  
                                                                 
                                                                <option value="1957">1957</option>  
                                                                 
                                                                <option value="1958">1958</option>  
                                                                 
                                                                <option value="1959">1959</option>  
                                                                 
                                                                <option value="1960">1960</option>  
                                                                 
                                                                <option value="1961">1961</option>  
                                                                 
                                                                <option value="1962">1962</option>  
                                                                 
                                                                <option value="1963">1963</option>  
                                                                 
                                                                <option value="1964">1964</option>  
                                                                 
                                                                <option value="1965">1965</option>  
                                                                 
                                                                <option value="1966">1966</option>  
                                                                 
                                                                <option value="1967">1967</option>  
                                                                 
                                                                <option value="1968">1968</option>  
                                                                 
                                                                <option value="1969">1969</option>  
                                                                 
                                                                <option value="1970">1970</option>  
                                                                 
                                                                <option value="1971">1971</option>  
                                                                 
                                                                <option value="1972">1972</option>  
                                                                 
                                                                <option value="1973">1973</option>  
                                                                 
                                                                <option value="1974">1974</option>  
                                                                 
                                                                <option value="1975">1975</option>  
                                                                 
                                                                <option value="1976">1976</option>  
                                                                 
                                                                <option value="1977">1977</option>  
                                                                 
                                                                <option value="1978">1978</option>  
                                                                 
                                                                <option value="1979">1979</option>  
                                                                 
                                                                <option value="1980">1980</option>  
                                                                 
                                                                <option value="1981">1981</option>  
                                                                 
                                                                <option value="1982">1982</option>  
                                                                 
                                                                <option value="1983">1983</option>  
                                                                 
                                                                <option value="1984">1984</option>  
                                                                 
                                                                <option value="1985">1985</option>  
                                                                 
                                                                <option value="1986">1986</option>  
                                                                 
                                                                <option value="1987">1987</option>  
                                                                 
                                                                <option value="1988">1988</option>  
                                                                 
                                                                <option value="1989">1989</option>  
                                                                 
                                                                <option value="1990">1990</option>  
                                                                 
                                                                <option value="1991">1991</option>  
                                                                 
                                                                <option value="1992">1992</option>  
                                                                 
                                                                <option value="1993">1993</option>  
                                                                 
                                                                <option value="1994">1994</option>  
                                                                 
                                                                <option value="1995">1995</option>  
                                                                 
                                                                <option value="1996">1996</option>  
                                                                 
                                                                <option value="1997">1997</option>  
                                                                 
                                                                <option value="1998">1998</option>  
                                                                 
                                                                <option value="1999">1999</option>  
                                                                 
                                                                <option value="2000">2000</option>  
                                                                 
                                                                <option value="2001">2001</option>  
                                                                 
                                                                <option value="2002">2002</option>  
                                                                 
                                                                <option value="2003">2003</option>  
                                                                 
                                                                <option value="2004">2004</option>  
                                                                 
                                                                <option value="2005">2005</option>  
                                                                 
                                                                <option value="2006">2006</option>  
                                                                 
                                                                <option value="2007">2007</option>  
                                                                 
                                                                <option value="2008">2008</option>  
                                                                 
                                                                <option value="2009">2009</option>  
                                                                 
                                                                <option value="2010">2010</option>  
                                                                 
                                                                <option value="2011">2011</option>  
                                                                 
                                                                <option value="2012">2012</option>  
                                                                 
                                                                <option value="2013">2013</option>  
                                                                 
                                                                <option value="2014">2014</option>  
                                                                 
                                                                <option value="2015">2015</option>  
                                                                 
                                                                <option value="2016">2016</option>  
                                                                 
                                                                <option value="2017">2017</option>  
                                                                 
                                                                <option value="2018">2018</option>  
                                                                 
                                                                <option value="2019">2019</option>  
                                                                                                                             </select>
                                                    </div>
                                                 </div>           
                                                <div class="col-md-3">
                                                   <div class="form-group">
                                                   	<label for="" class="visible-xs">Membership No</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="membership_no4" name="membership_no4" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="row">
                                            	<div class="col-md-1 hidden-xs">
                                                    <div class="form-group">
                                                        5
                                                    </div>
                                                </div>
                                                <div class="col-md-3">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Name Of Authorized Nominees</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="nominee5" name="nominee5" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="col-md-5">
                                                    <div class="form-group">
                                                    	<label for="" class="visible-xs">Date of Birth</label>
                                                             <select id="birth_date5" name="birth_date5" tabindex="-1" title="" class="form-control">
                                                                  <option value="">--Select--</option>
                                                                 
                                                                <option value="01">01</option>  
                                                                 
                                                                <option value="02">02</option>  
                                                                 
                                                                <option value="03">03</option>  
                                                                 
                                                                <option value="04">04</option>  
                                                                 
                                                                <option value="05">05</option>  
                                                                 
                                                                <option value="06">06</option>  
                                                                 
                                                                <option value="07">07</option>  
                                                                 
                                                                <option value="08">08</option>  
                                                                 
                                                                <option value="09">09</option>  
                                                                 
                                                                <option value="10">10</option>  
                                                                 
                                                                <option value="11">11</option>  
                                                                 
                                                                <option value="12">12</option>  
                                                                 
                                                                <option value="13">13</option>  
                                                                 
                                                                <option value="14">14</option>  
                                                                 
                                                                <option value="15">15</option>  
                                                                 
                                                                <option value="16">16</option>  
                                                                 
                                                                <option value="17">17</option>  
                                                                 
                                                                <option value="18">18</option>  
                                                                 
                                                                <option value="19">19</option>  
                                                                 
                                                                <option value="20">20</option>  
                                                                 
                                                                <option value="21">21</option>  
                                                                 
                                                                <option value="22">22</option>  
                                                                 
                                                                <option value="23">23</option>  
                                                                 
                                                                <option value="24">24</option>  
                                                                 
                                                                <option value="25">25</option>  
                                                                 
                                                                <option value="26">26</option>  
                                                                 
                                                                <option value="27">27</option>  
                                                                 
                                                                <option value="28">28</option>  
                                                                 
                                                                <option value="29">29</option>  
                                                                 
                                                                <option value="30">30</option>  
                                                                 
                                                                <option value="31">31</option>  
                                                                                                                             </select>

                                                             <select id="birth_month5" name="birth_month5" tabindex="-1" title="" class="form-control">
                                                                <option value="">--Select--</option>
                                                                <option value="Jan">Jan</option>
                                                                 <option value="Feb">Feb</option> 
                                                                 <option value="Mar">Mar</option> 
                                                                 <option value="Apr">Apr</option> 
                                                                 <option value="May">May</option>
                                                                 <option value="Jun">Jun</option> 
                                                                 <option value="Jul">Jul</option> 
                                                                 <option value="Aug">Aug</option>
                                                                 <option value="Sep">Sep</option> 
                                                                 <option value="Oct">Oct</option> 
                                                                 <option value="Nov">Nov</option> 
                                                                 <option value="Dec">Dec</option> 
                                                            </select>

                                                             <select id="birth_year5" name="birth_year5" tabindex="-1" title="" class="form-control">
                                                                 <option value="">--Select--</option>
                                                                 
                                                                <option value="1930">1930</option>  
                                                                 
                                                                <option value="1931">1931</option>  
                                                                 
                                                                <option value="1932">1932</option>  
                                                                 
                                                                <option value="1933">1933</option>  
                                                                 
                                                                <option value="1934">1934</option>  
                                                                 
                                                                <option value="1935">1935</option>  
                                                                 
                                                                <option value="1936">1936</option>  
                                                                 
                                                                <option value="1937">1937</option>  
                                                                 
                                                                <option value="1938">1938</option>  
                                                                 
                                                                <option value="1939">1939</option>  
                                                                 
                                                                <option value="1940">1940</option>  
                                                                 
                                                                <option value="1941">1941</option>  
                                                                 
                                                                <option value="1942">1942</option>  
                                                                 
                                                                <option value="1943">1943</option>  
                                                                 
                                                                <option value="1944">1944</option>  
                                                                 
                                                                <option value="1945">1945</option>  
                                                                 
                                                                <option value="1946">1946</option>  
                                                                 
                                                                <option value="1947">1947</option>  
                                                                 
                                                                <option value="1948">1948</option>  
                                                                 
                                                                <option value="1949">1949</option>  
                                                                 
                                                                <option value="1950">1950</option>  
                                                                 
                                                                <option value="1951">1951</option>  
                                                                 
                                                                <option value="1952">1952</option>  
                                                                 
                                                                <option value="1953">1953</option>  
                                                                 
                                                                <option value="1954">1954</option>  
                                                                 
                                                                <option value="1955">1955</option>  
                                                                 
                                                                <option value="1956">1956</option>  
                                                                 
                                                                <option value="1957">1957</option>  
                                                                 
                                                                <option value="1958">1958</option>  
                                                                 
                                                                <option value="1959">1959</option>  
                                                                 
                                                                <option value="1960">1960</option>  
                                                                 
                                                                <option value="1961">1961</option>  
                                                                 
                                                                <option value="1962">1962</option>  
                                                                 
                                                                <option value="1963">1963</option>  
                                                                 
                                                                <option value="1964">1964</option>  
                                                                 
                                                                <option value="1965">1965</option>  
                                                                 
                                                                <option value="1966">1966</option>  
                                                                 
                                                                <option value="1967">1967</option>  
                                                                 
                                                                <option value="1968">1968</option>  
                                                                 
                                                                <option value="1969">1969</option>  
                                                                 
                                                                <option value="1970">1970</option>  
                                                                 
                                                                <option value="1971">1971</option>  
                                                                 
                                                                <option value="1972">1972</option>  
                                                                 
                                                                <option value="1973">1973</option>  
                                                                 
                                                                <option value="1974">1974</option>  
                                                                 
                                                                <option value="1975">1975</option>  
                                                                 
                                                                <option value="1976">1976</option>  
                                                                 
                                                                <option value="1977">1977</option>  
                                                                 
                                                                <option value="1978">1978</option>  
                                                                 
                                                                <option value="1979">1979</option>  
                                                                 
                                                                <option value="1980">1980</option>  
                                                                 
                                                                <option value="1981">1981</option>  
                                                                 
                                                                <option value="1982">1982</option>  
                                                                 
                                                                <option value="1983">1983</option>  
                                                                 
                                                                <option value="1984">1984</option>  
                                                                 
                                                                <option value="1985">1985</option>  
                                                                 
                                                                <option value="1986">1986</option>  
                                                                 
                                                                <option value="1987">1987</option>  
                                                                 
                                                                <option value="1988">1988</option>  
                                                                 
                                                                <option value="1989">1989</option>  
                                                                 
                                                                <option value="1990">1990</option>  
                                                                 
                                                                <option value="1991">1991</option>  
                                                                 
                                                                <option value="1992">1992</option>  
                                                                 
                                                                <option value="1993">1993</option>  
                                                                 
                                                                <option value="1994">1994</option>  
                                                                 
                                                                <option value="1995">1995</option>  
                                                                 
                                                                <option value="1996">1996</option>  
                                                                 
                                                                <option value="1997">1997</option>  
                                                                 
                                                                <option value="1998">1998</option>  
                                                                 
                                                                <option value="1999">1999</option>  
                                                                 
                                                                <option value="2000">2000</option>  
                                                                 
                                                                <option value="2001">2001</option>  
                                                                 
                                                                <option value="2002">2002</option>  
                                                                 
                                                                <option value="2003">2003</option>  
                                                                 
                                                                <option value="2004">2004</option>  
                                                                 
                                                                <option value="2005">2005</option>  
                                                                 
                                                                <option value="2006">2006</option>  
                                                                 
                                                                <option value="2007">2007</option>  
                                                                 
                                                                <option value="2008">2008</option>  
                                                                 
                                                                <option value="2009">2009</option>  
                                                                 
                                                                <option value="2010">2010</option>  
                                                                 
                                                                <option value="2011">2011</option>  
                                                                 
                                                                <option value="2012">2012</option>  
                                                                 
                                                                <option value="2013">2013</option>  
                                                                 
                                                                <option value="2014">2014</option>  
                                                                 
                                                                <option value="2015">2015</option>  
                                                                 
                                                                <option value="2016">2016</option>  
                                                                 
                                                                <option value="2017">2017</option>  
                                                                 
                                                                <option value="2018">2018</option>  
                                                                 
                                                                <option value="2019">2019</option>  
                                                                                                                             </select>
                                                    </div>
                                                 </div>  
                                                <div class="col-md-3">
                                                   <div class="form-group">
                                                   	<label for="" class="visible-xs">Membership No</label>
                                                        <div class="input-group">
                                                            <input class="form__text form-control" id="membership_no5" name="membership_no5" type="text" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                    </div>
                                     <span id="spnnominee" style="display:none;"></span>
                                </div>  
                                <div class="col-md-2 col-lg-2 col-sm-2"></div>
                                <div class="col-md-10 col-lg-10 col-sm-10">
                                <h3>Service Fees</h3>
                                		<div class="form-group price_rs_mile">                            
                                            <input type="radio" id="first_nomination" name="price_rs_miles" class="form__text form-control price_rs_miles" value="First Time Nomination" checked>
                                            <label for="first_nomination">First Time Nomination</label>
                                           <!-- <p>This is my first nomination and I understand there is no fee involved.</p>-->
                                    </div>				
                                <h4 class="ser_head">Changes to current nominee</h4>
                                <p>I would like to make changes to my current list of nominees. I understand that any change or deletion will incur a service fee. Any further change can only be carried out after a 12 month period.Please select service fee below:	</p>
                                <!--div class="form-group price_rs_mile">                            
                                            <input type="radio" id="price_rs_miles" name="price_rs_miles" class="form__text form-control price_rs_miles" value="3,000 Royal Skies Miles" checked>
                                            <label for="price_rs_miles">3,000 Royal Skies Miles</label>
                                    </div-->
                                 <div class="form-group price_rs_mile">                            
                                            <input type="radio" id="usd_rs_miles" name="price_rs_miles" class="form__text form-control price_rs_miles" value="USD30">
                                            <label for="usd_rs_miles">USD30</label>
                                    </div>
                            </div>
                                <div class="col-md-2 col-lg-2 col-sm-2"></div>
                                <div class="col-md-10 col-lg-10 col-sm-10">
                            <div class="checkbox-margin">
                                  <div class="form-group checkbox-label">
                                        <input name="check_box_custom1[]" type="checkbox" class="checkbox authorise1" value="I understand that the list of nominees named here will override any previous list of nominees (if any) that I have submitted. Below are the nominee(s) whom I authorize to make bookings and collect redemption tickets from Royal Brunei Customer Service Centre for themselves and on my behalf." id="authorise1" required/>
                                        <label for="authorise1" class="agree_check">
                                            <span></span>
                                           I understand that the list of nominees named here will override any previous list of nominees (if any) that I have submitted. Below are the nominee(s) whom I authorize to make bookings and collect redemption tickets from Royal Brunei Customer Service Centre for themselves and on my behalf. 
                                        </label>
                                     </div>
                                  <div class="form-group checkbox-label2">
                                        <input name="check_box_custom2[]" type="checkbox" class="checkbox authorise2" value="I hereby authorize Royal Brunei Airlines to issue free awards (subject to the Terms and Conditions of the programme) to the following nominee(s) in exchange for Royal Skies Miles." id="authorise2" required/>
                                        <label for="authorise2" class="agree_check">
                                            <span></span>
                                           	I hereby authorize Royal Brunei Airlines to issue free awards (subject to the Terms and Conditions of the programme) to the following nominee(s) in exchange for Royal Skies Miles.
                                        </label>
                                     </div>
                            </div>
                            <!-- <div class="g-recaptcha" data-sitekey=""></div> -->
                            <div class="g-recaptcha captcha-container" data-sitekey="6LfLI6UrAAAAAGbrB-MIYfE1vP_VBHznw_-n_7EO" data-badge="inline" data-size="invisible" data-callback="setResponse"></div>
    						<input type="hidden" id="captcha-response" name="captcha-response" />
                            <input type="submit" value="Submit" class="enquiry" name="member_redemption">
                        </div>
                                <div class="col-md-2 col-lg-2 col-sm-2"></div>
                             </div>
            </form>
            <script>
            var onloadCallback = function() {
			    grecaptcha.execute();
			};
			function setResponse(response) { 
			    document.getElementById('captcha-response').value = response; 
			}
			</script>
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