<div class="um um-register um-1703">
	<div class="um-form" data-mode="register">
		<form method="post" action="">
			<div class="um-row _um_row_1 " style="margin: 0 0 30px 0;"><div class="um-col-1"><div id="um_field_1703_user_login" class="um-field um-field-text um-field-user_login um-field-text um-field-type_text" data-key="user_login"><div class="um-field-label"><label for="user_login-1703">Username<span class="um-req" title="Required">*</span></label><div class="um-clear"></div></div><div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="user_login-1703" id="user_login-1703" value="" placeholder="" data-validate="unique_username" data-key="user_login" aria-invalid="false" />

						</div></div><div id="um_field_1703_first_name" class="um-field um-field-text um-field-first_name um-field-text um-field-type_text" data-key="first_name"><div class="um-field-label"><label for="first_name-1703">First Name</label><div class="um-clear"></div></div><div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="first_name-1703" id="first_name-1703" value="" placeholder="" data-validate="" data-key="first_name" aria-invalid="false" />

						</div></div><div id="um_field_1703_last_name" class="um-field um-field-text um-field-last_name um-field-text um-field-type_text" data-key="last_name"><div class="um-field-label"><label for="last_name-1703">Last Name</label><div class="um-clear"></div></div><div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="last_name-1703" id="last_name-1703" value="" placeholder="" data-validate="" data-key="last_name" aria-invalid="false" />

						</div></div><div id="um_field_1703_user_email" class="um-field um-field-text um-field-user_email um-field-text um-field-type_text" data-key="user_email"><div class="um-field-label"><label for="user_email-1703">E-mail Address</label><div class="um-clear"></div></div><div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="user_email-1703" id="user_email-1703" value="" placeholder="" data-validate="unique_email" data-key="user_email" aria-invalid="false" />

						</div></div><div id="um_field_1703_user_password" class="um-field um-field-password um-field-user_password um-field-password um-field-type_password" data-key="user_password"><div class="um-field-label"><label for="user_password-1703">Password<span class="um-req" title="Required">*</span></label><div class="um-clear"></div></div><div class="um-field-area"><input class="um-form-field valid " type="password" name="user_password-1703" id="user_password-1703" value="" placeholder="" data-validate="" data-key="user_password" aria-invalid="false" />

							</div></div><div id="um_field_1703_confirm_user_password" class="um-field um-field-password um-field-user_password um-field-password um-field-type_password" data-key="confirm_user_password"><div class="um-field-label"><label for="confirm_user_password-1703">Confirm Password<span class="um-req" title="Required">*</span></label><div class="um-clear"></div></div><div class="um-field-area"><input class="um-form-field valid " type="password" name="confirm_user_password-1703" id="confirm_user_password-1703" value="" placeholder="Confirm Password" data-validate="" data-key="confirm_user_password" aria-invalid="false" /></div></div></div></div>	<input type="hidden" name="form_id" id="form_id_1703" value="1703" />
		<p class="um_request_name">
		<label for="um_request_1703">Only fill in if you are not human</label>
		<input type="hidden" name="um_request" id="um_request_1703" class="input" value="" size="25" autocomplete="off" />
	</p>
	<input type="hidden" id="_wpnonce" name="_wpnonce" value="4134cedad9" /><input type="hidden" name="_wp_http_referer" value="/register/amp/" />
	<div class="um-col-alt">

		
			<div class="um-left um-half">
				<input type="submit" value="Register" class="um-button" id="um-submit-btn" />
			</div>
			<div class="um-right um-half">
				<a href="https://leverage.com.pk/login/amp/" class="um-button um-alt">
					Login				</a>
			</div>

		
		<div class="um-clear"></div>

	</div>

			</form>
	</div>
</div>
<style>
			.um-1703.um {
			max-width: 450px;
		}
		</style>