+ </div>
+
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div>
+ <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_last_name' required></div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
+ <div class='col-sm-6'>
+ <div class="input-group date">
+ <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control input-lg" required>
+ </div>
+ <script>
+ var $d = jQuery.noConflict();
+ $d('.input-group.date').datepicker({
+ format: "mm/dd/yyyy",
+ clearBtn: true
+ });
+ </script>
+ </div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>Phone Number</h2></div>
+ <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" id="contact_phone" name="contact_phone" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" required></div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div>
+ <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div>
+ <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number' required> </div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House Format</h3></div>
+ <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>321</h3></div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div>
+ <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number' required> </div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div>
+ <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-10' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block"><img class='click_me' src="files/click_here.gif">Next</button></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-10' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block not_me">Clear</button></div>
+ </div>