<div class="et_pb_module et_pb_login et_pb_login_0 et_pb_newsletter clearfix et_pb_bg_layout_dark et_pb_text_align_left" style="background-color: #007c85;"><!-- [et_pb_line_break_holder] --> <div class="et_pb_newsletter_description"><!-- [et_pb_line_break_holder] --> <h2 class="et_pb_module_header">MyPCH Registration</h2><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="et_pb_newsletter_form et_pb_login_form"><!-- [et_pb_line_break_holder] --> <form action="https://9n8.2a4.myftpupload.com/my-pch/register2.php?goto=register" method="post" id="registrationform" name="registrationform"><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <label class="et_pb_contact_form_label" for="user_login_5afddb7cbd5a7" style="display: none;">Username</label><!-- [et_pb_line_break_holder] --> <input name="registrationusername" value="registrationusername" tabindex="1" placeholder="Username" class="input" type="text"><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <label class="et_pb_contact_form_label" for="user_login_5afddb7cbd5a7" style="display: none;">Your Email</label><!-- [et_pb_line_break_holder] --> <input name="registrationemail" value="registrationemail" tabindex="1" placeholder="Your Email" class="input" type="text"><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <label class="et_pb_contact_form_label" for="user_pass_5afddb7cbd5a7" style="display: none;">Password</label><!-- [et_pb_line_break_holder] --> <input name="registrationpassword1" id="registrationpassword1" class="input" tabindex="2" placeholder="Password" value="" type="password"> <!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <label class="et_pb_contact_form_label" for="user_pass_5afddb7cbd5a7" style="display: none;">Confirm Password</label><!-- [et_pb_line_break_holder] --> <input name="registrationpassword1" id="registrationpassword1" class="input" tabindex="2" placeholder="Confirm Password" value="" type="password"> <!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <p class="et_pb_forgot_password"><a href="https://9n8.2a4.myftpupload.com/my-pch/news/admin.php?action=recoverpass">Forgot your password?</a></p><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> <input name="register_submit" value="Register" class="et_pb_newsletter_button et_pb_button" type="submit"><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div>