User Registeration

I am a
 
Name*
 
Email Id*
 
Password
 
Confirm Password
 
Gender
Male Female
 
Date of birth*
 
Country*
 
City*
    if city not in list
Country Code
 
STD Code
 
Landline Number
  If you have multiple contact numbers, you can add them by a comma
 
Mobile Number
  If you have multiple contact numbers, you can add them by a comma
 
Enter Code* captcha using image validation