+ <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 oninvalid="this.setCustomValidity('Please enter only your last name')" oninput="this.setCustomValidity('')"></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 oninvalid="this.setCustomValidity('Please enter your date of birth in the format month month slash day day slash year year year year')" oninput="this.setCustomValidity('')">
+ </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 oninvalid="this.setCustomValidity('please enter your phone number with area code with hyphens like 1 2 3 dash 4 5 6 dash 7 8 9 0')" oninput="this.setCustomValidity('')"></div>
+ <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div>