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<style type="text/css">
.inputform{
	width:800px;
	 display: block;
	 margin-left: auto;
	 margin-right: auto;
	 color:black;
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@media screen and (max-width:800px) {
	.inputform{
		width:100%;
		display: block;
		margin-left: auto;
		margin-right: auto;
		 color:black;
	}
}
table {
	color:black;
}
</style>
    <link rel="stylesheet" href="https://www.marrix.co.jp/common/sp/css/reset.css" media="all">
    <link rel="stylesheet" href="https://www.marrix.co.jp/common/sp/css/base.css" media="all">
    <link rel="stylesheet" href="https://www.marrix.co.jp/common/sp/css/form.css" media="all">

<div class="wrapper">
<!--=======================コンテンツのhtml=============================================-->
		<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.4.2/jquery.min.js"></script>
		<script type="text/javascript" src="https://ajaxzip3.github.io/ajaxzip3.js" charset="utf-8"></script>
        <div class="headline01">
          <h2></h2>
        </div>
        <div class="btn_tel">
          <h3><a href="tel:0120042304">フリーコール：0120-04-2304</a></h3>    
        </div>
    	<div class="inputform">
	   	<form id="marrix" name="marrix" action="https://wp.marrix.co.jp/wordpress/wp-content/plugins/MARRIXREGIST/regist1.php" method="post">    
			<input type="hidden" id="para" name="para" value="">
			<table style="color:black;">
			<tr>
			<td colspan="2">
				<p id="form_start"><img src="https://www.marrix.co.jp/common/sp/img/regist/regist_flow01.png" alt="プロフィールのご入力" class="img_responsibe"></p>
			</td>
			</tr>
			<tr>
				<td style="width:100px;">性別<span style="color:red;font-size:x-small;"> 必須です </span></td>
				<td>
					
									      <input type="radio" name="sex" value="男性" checked>男性&nbsp;
				      <input type="radio" name="sex" value="女性">女性
				    				  </td>
			</tr>
			<tr>
				<td style="width:100px;">生年<span style="color:red;font-size:x-small;"> 必須です </span></td>
				<td>
				    <select id="birthyear" name="birthyear" size="1" class="validate[required]">
					<option value="2007">2005H19</option><option value="2006">2005H18</option><option value="2005">2005H17</option><option value="2004">2004H16</option><option value="2003">2003H15</option><option value="2002">2002H14</option><option value="2001">2001H13</option><option value="2000">2000H12</option><option value="1999">1999H11</option><option value="1998">1998H10</option><option value="1997">1997H09</option><option value="1996">1996H08</option><option value="1995">1995H07</option><option value="1994">1994H06</option><option value="1993">1993H05</option><option value="1992">1992H04</option><option value="1991">1991H03</option><option value="1990">1990H02</option><option value="1989">1989H01</option><option value="1988">1988S63</option><option value="1987">1987S62</option><option value="1986">1986S61</option><option value="1985">1985S60</option><option value="1984">1984S59</option><option value="1983">1983S58</option><option value="1982">1982S57</option><option value="1981">1981S56</option><option value="1980">1980S55</option><option value="1979">1979S54</option><option value="1978">1978S53</option><option value="1977">1977S52</option><option value="1976">1976S51</option><option value="1975">1975S50</option><option value="1974">1974S49</option><option value="1973">1973S48</option><option value="1972">1972S47</option><option value="1971">1971S46</option><option value="1970">1970S45</option><option value="1969">1969S44</option><option value="1968">1968S43</option><option value="1967">1967S42</option><option value="1966">1966S41</option><option value="1965">1965S40</option><option value="1964">1964S39</option><option value="1963">1963S38</option><option value="1962">1962S37</option><option value="1961">1961S36</option><option value="1960">1960S35</option><option value="1959">1959S34</option><option value="1958">1958S33</option><option value="1957">1957S32</option><option value="1956">1956S31</option><option value="1955">1955S30</option><option value="1954">1954S29</option><option value="1953">1953S28</option><option value="1952">1952S27</option><option value="1951">1951S26</option><option value="1950">1950S25</option><option value="1949">1949S24</option><option value="1948">1948S23</option><option value="1947">1947S22</option><option value="1946">1946S21</option><option value="1945">1945S20</option><option value="1944">1944S19</option><option value="1943">1943S18</option><option value="1942">1942S17</option><option value="1941">1941S16</option><option value="1940">1940S15</option><option value="1939">1939S14</option><option value="1938">1938S13</option><option value="1937">1937S12</option><option value="1936">1936S11</option><option value="1935">1935S10</option><option value="1934">1934S09</option><option value="1933">1933S08</option><option value="1932">1932S07</option><option value="1931">1931S06</option><option value="1930">1930S05</option><option value="1929">1929S04</option><option value="1928">1928S03</option><option value="1927">1927S02</option><option value="1926">1926S01</option>				     </select>
				</td
			</tr>
			<tr>
				<td style="width:100px;">婚歴<span style="color:red;font-size:x-small;"> 必須です </span></td>
				<td>
				    				      <input type="radio" name="marriage" value="初婚" checked="">初婚&nbsp;
				      <input type="radio" name="marriage" value="再婚">再婚
				    				</td>
			</tr>
			<tr>
				<td style="width:100px;">学歴<span style="color:red;font-size:x-small;">必須です</span></td>
				<td>
				    <select id="study" name="study" size="1" class="validate[required]">
				      <option value="" style="color: black;">選択してください</option>
				       				      <option value="大学院" style="color: black;">大学院</option>
				      <option value="大学" style="color: black;">大学</option>
				      <option value="短大・専門" style="color: black;">短大・専門</option>
				      <option value="高校" style="color: black;">高校</option>
				      				     </select>
				  </td>
			</tr>
			<tr>
				<td colspan="2">
				<p id="form_start"><img src="https://www.marrix.co.jp/common/sp/img/regist/regist_flow02.png" alt="お届け先のご入力" class="img_responsibe"></p>
				<h6>郵送をご希望の方は住所をご入力ください。</h6>
				</td>
			</tr>
			<tr>
				<td style="width:100px;">氏名<span style="color:red;font-size:x-small;">必須項目です</span></td>
				<td>
				    <input type="text" id="name" class="input_text validate[required]" name="name" size="40" value="" style="ime-mode: active;" placeholder="例）東　　真理子" onpaste="return false;" required>
				</td>
			</tr>
			<tr>
				<td style="width:100px;">かな氏名<span style="color:red;font-size:x-small;">必須項目です</span></td>
				<td>
				    <input type="text" id="name_kana" name="name_kana" size="40" value="" class="input_text validate[required]" placeholder="例）あずま　　まりこ" onpaste="return false;" required>
				</td>
			</tr>
			<tr>
				<td style="width:100px;">メールアドレス<span style="color:red;font-size:x-small;">必須項目です</span></td>
				<td>
				    <input type="email" style="ime-mode: disabled;" class="input_text validate[required,custom[email]]" name="mail" size="40" value="" placeholder="例）info@marrix.co.jp" onpaste="return false;">
				</td>
			</tr>
			<tr>
				<td style="width:100px;">お電話番号<span style="color:red;font-size:x-small;">必須項目です</span></td>
				<td>
				    <input type="tel" class="input_text validate[required,custom[phone]]" style="ime-mode: disabled;" name="tell" id="tell" size="40" value="" placeholder="例）03-3349-0401 又は 0333490401" onpaste="return false;" required>
				</td>
			</tr>
			<tr>
				<td style="width:100px;">郵便番号</td>
				<td>
				    <input id="zip" type="tel" name="zip" style="ime-mode: disabled;" value="" placeholder="163-0444 又は 1630444" onkeyup="AjaxZip3.zip2addr('zip', '', 'ken', 'address')" onpaste="return false;">
				</td>
			</tr>
			<tr>
				<td style="width:100px;">都道府県</td>
				<td>
					<input id="ken" type="text" name="ken" size="20" value="" class="input_text">
				</td>
			</tr>
			<tr>
				<td style="width:100px;">市区町村</td>
				<td>
				    <input id="address" type="text" name="address" size="40" value="" class="input_text" placeholder="新宿区西新宿">
				</td>
			</tr>
			<tr>
				<td style="width:100px;">番地</td>
				<td>
				    <input id="address_num"  type="text" name="address_num" size="40" value="" class="input_text" placeholder="2-1-1">
				</td>
			</tr>
			<tr>
				<td style="width:100px;">マンション名</td>
				<td>
				    <input id="address_name" type="text" name="address_name" size="40" value="" class="input_text" placeholder="新宿三井ビル44階">
				</td>
			</tr>
			<tr>
				<td colspan="2">自由記述　ご意見・ご要望など </td>
			</tr>
			<tr>
				<td colspan="2">
				    <textarea name="memo" class="textarea_s"></textarea>
				</td>
			</tr>
		</table>
		
        <div style="background-color:#cab8d9;black;padding:10px;">
		  <p class="security_tit">個人情報の取り扱いについて</p>
          <p style="text-align:left;background-color:white;color:black;padding:5px;">
			ご記入いただいた個人情報は、資料送付と入会のご案内に使用させていただきます。第三者への提供及び配送以外での外部に委託はいたしません。
            ご記入は任意ですが、必要項目に記入が無い場合パンフレットをお送りできないことがあります。
            個人情報に関する開示・内容の訂正・追加又は削除、利用の停止、消去、第三者への提供の停止、第三者提供記録の開示は下記の問い合わせ窓口にお願い致します。<br>
          </p>
          <p style="text-align:left;background-color:white;color:black;padding:5px;">
			<b>株式会社シニアーライフ（マリックス）問い合わせ窓口</b><br>
			・問合担当　個人情報保護管理責任者　木村秀毅<br>
			・所在地　　東京都渋谷区渋谷2-9-10 キングビル7階<br>
			・電話番号　03-3349-0401<br>
			・E-Mail 　info@marrix.co.jp<br>
			</p>
          </div>
          <div>
            <input  style="background-color:orange;color:white;font-size:2em;" type="submit" value="確認画面へ進む"><span class="arrow"></span>
          </div>
  
		</form>
		</div>
	</div><!--cont_outerの閉じ-->
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