<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.0.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <div class="row"> <div class="rover-primary-col rover-single-col col-center col-md-10 col-lg-7 margin-top-x5 "> <div class="rover-primary-content-block"> <header class="rover-page-header"> <h1 class="rover-header-title"></h1> <h3 class="rover-header-subtitle"></h3> </header> <div class="new-design js-alerts-container"></div> <form method="POST" name="account_info_form" enctype="multipart/form-data" class="js-account-info-form" novalidate="novalidate"> <div class="account-profile-section-header margin-bottom-x5"> <h3>Let's start with the basics</h3> </div> <div class="row margin-top-x4"> <div class="col-lg-12"> <h5 class="ssu-form-header"><strong>Add your address</strong></h5> <input type="hidden" name="csrfmiddlewaretoken" value="6gh5xe1GqY51AbV6fIwpY4AYfUHD2TDP" /> <div class="row"> <div class="col-12"> <div id="div_id_account_information-address_line1" class="form-group"> <label for="id_account_information-address_line1" class="form-control-label requiredField">Address line 1<span class="asteriskField">*</span> </label> <div class="controls "> <input class="textinput textInput form-control" id="id_account_information-address_line1" maxlength="50" name="account_information-address_line1" required="required" type="text" /> </div> </div> </div> </div> <div class="row"> <div class="col-12"> <div id="div_id_account_information-address_line2" class="form-group"> <label for="id_account_information-address_line2" class="form-control-label ">Address line 2</label> <div class="controls "> <input class="textinput textInput form-control" id="id_account_information-address_line2" maxlength="50" name="account_information-address_line2" type="text" /> </div> </div> </div> </div> <div class="row" split="[4, 4, 4]"> <div class="col-md-4"> <div id="div_id_account_information-city" class="form-group"> <label for="id_account_information-city" class="form-control-label requiredField">City<span class="asteriskField">*</span> </label> <div class="controls "> <input class="textinput textInput form-control" id="id_account_information-city" maxlength="75" name="account_information-city" required="required" type="text" /> </div> </div> </div> <div class="col-md-4"> <div id="div_id_account_information-state" class="form-group"> <label for="id_account_information-state" class="form-control-label requiredField">State or province<span class="asteriskField">*</span> </label> <div class="controls "> <select class="roverusstateorcaprovinceselect form-control" id="id_account_information-state" name="account_information-state" required="required"> <option value="" selected="selected">---------</option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="DC">District of Columbia</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VI">Virgin Islands</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> <option value="">---------</option> <option value="AB">Alberta</option> <option value="BC">British Columbia</option> <option value="MB">Manitoba</option> <option value="NB">New Brunswick</option> <option value="NL">Newfoundland and Labrador</option> <option value="NT">Northwest Territories</option> <option value="NS">Nova Scotia</option> <option value="NU">Nunavut</option> <option value="ON">Ontario</option> <option value="PE">Prince Edward Island</option> <option value="QC">Quebec</option> <option value="SK">Saskatchewan</option> <option value="YT">Yukon</option> </select> </div> </div> </div> <div class="col-md-4"> <div id="div_id_account_information-zip" class="form-group"> <label for="id_account_information-zip" class="form-control-label requiredField">ZIP or postal code<span class="asteriskField">*</span> </label> <div class="controls "> <input class="textinput textInput form-control" data-msg-pattern="Please enter a valid US ZIP code or Canadian postal code." data-msg-remote="Please enter a valid US ZIP code or Canadian postal code." data-rule-remote="/ajax/validate/zip_code/" id="id_account_information-zip" name="account_information-zip" pattern="(^\d{5}(?:-\d{4})?$)|(^([ABCEGHJKLMNPRSTVXYabceghjklmnprstvxy]\d[ABCEGHJKLMNPRSTVWXYZabceghjklmnprstvwxyz])\s*(\d[ABCEGHJKLMNPRSTVWXYZabceghjklmnprstvwxyz]\d)$)" required="required" type="text" value="3090" /> </div> </div> </div> </div> </div> </div> <div class="row"> <div class="col-lg-12"> <div class="account-profile-section-header"> <h3>Personal Information</h3> <p class="body-text text-muted">We won't share or display this on your profile.</p> </div> <input type="hidden" name="csrfmiddlewaretoken" value="6gh5xe1GqY51AbV6fIwpY4AYfUHD2TDP" /> <div class="row"> <div class="col-12"> <div id="div_id_private_information-email" class="form-group"> <label for="id_private_information-email" class="form-control-label requiredField">Email<span class="asteriskField">*</span> </label> <div class="controls "> <input class="emailinput form-control" id="id_private_information-email" name="private_information-email" required="required" type="email" value="medina-fetterman.1@buckeyemail.osu.edu" /> </div> </div> </div> </div> <div class="row"> <div class="col-12"> <div id="div_id_private_information-birthdate" class="form-group"> <label for="id_private_information-birthdate_month" class="form-control-label ">What is your birthday?</label> <div class="controls "> <div class="row birthdate-widget"> <div class="col-4"> <select class="birthdatewidget form-control" id="id_private_information-birthdate_month" name="private_information-birthdate_month"> <option value="" selected="selected">Month</option> <option value="1">January</option> <option value="2">February</option> <option value="3">March</option> <option value="4">April</option> <option value="5">May</option> <option value="6">June</option> <option value="7">July</option> <option value="8">August</option> <option value="9">September</option> <option value="10">October</option> <option value="11">November</option> <option value="12">December</option> </select> </div> <div class="col-4"> <select class="birthdatewidget form-control" id="id_private_information-birthdate_day" name="private_information-birthdate_day"> <option value="" selected="selected">Day</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30">30</option> <option value="31">31</option> </select> </div> <div class="col-4"> <select class="birthdatewidget form-control" id="id_private_information-birthdate_year" name="private_information-birthdate_year"> <option value="" selected="selected">Year</option> <option value="2016">2016</option> <option value="2015">2015</option> <option value="2014">2014</option> <option value="2013">2013</option> <option value="2012">2012</option> <option value="2011">2011</option> <option value="2010">2010</option> <option value="2009">2009</option> <option value="2008">2008</option> <option value="2007">2007</option> <option value="2006">2006</option> <option value="2005">2005</option> <option value="2004">2004</option> <option value="2003">2003</option> <option value="2002">2002</option> <option value="2001">2001</option> <option value="2000">2000</option> <option value="1999">1999</option> <option value="1998">1998</option> <option value="1997">1997</option> <option value="1996">1996</option> <option value="1995">1995</option> <option value="1994">1994</option> <option value="1993">1993</option> <option value="1992">1992</option> <option value="1991">1991</option> <option value="1990">1990</option> <option value="1989">1989</option> <option value="1988">1988</option> <option value="1987">1987</option> <option value="1986">1986</option> <option value="1985">1985</option> <option value="1984">1984</option> <option value="1983">1983</option> <option value="1982">1982</option> <option value="1981">1981</option> <option value="1980">1980</option> <option value="1979">1979</option> <option value="1978">1978</option> <option value="1977">1977</option> <option value="1976">1976</option> <option value="1975">1975</option> <option value="1974">1974</option> <option value="1973">1973</option> <option value="1972">1972</option> <option value="1971">1971</option> <option value="1970">1970</option> <option value="1969">1969</option> <option value="1968">1968</option> <option value="1967">1967</option> <option value="1966">1966</option> <option value="1965">1965</option> <option value="1964">1964</option> <option value="1963">1963</option> <option value="1962">1962</option> <option value="1961">1961</option> <option value="1960">1960</option> <option value="1959">1959</option> <option value="1958">1958</option> <option value="1957">1957</option> <option value="1956">1956</option> <option value="1955">1955</option> <option value="1954">1954</option> <option value="1953">1953</option> <option value="1952">1952</option> <option value="1951">1951</option> <option value="1950">1950</option> <option value="1949">1949</option> <option value="1948">1948</option> <option value="1947">1947</option> <option value="1946">1946</option> <option value="1945">1945</option> <option value="1944">1944</option> <option value="1943">1943</option> <option value="1942">1942</option> <option value="1941">1941</option> <option value="1940">1940</option> <option value="1939">1939</option> <option value="1938">1938</option> <option value="1937">1937</option> <option value="1936">1936</option> <option value="1935">1935</option> <option value="1934">1934</option> <option value="1933">1933</option> <option value="1932">1932</option> <option value="1931">1931</option> <option value="1930">1930</option> <option value="1929">1929</option> <option value="1928">1928</option> <option value="1927">1927</option> <option value="1926">1926</option> <option value="1925">1925</option> <option value="1924">1924</option> <option value="1923">1923</option> <option value="1922">1922</option> <option value="1921">1921</option> <option value="1920">1920</option> <option value="1919">1919</option> <option value="1918">1918</option> <option value="1917">1917</option> </select> </div> </div> </div> </div> </div> </div> <div class="row"> <div class="col-12"> <div id="div_id_private_information-gender" class="form-group"> <label for="id_private_information-gender" class="form-control-label ">Gender (optional)</label> <div class="controls "> <select class="select form-control" id="id_private_information-gender" name="private_information-gender"> <option value="" selected="selected">---------</option> <option value="m">Male</option> <option value="f">Female</option> </select> </div> </div> </div> </div> </div> </div> <div class="padding-top-x5"> <div class="padding-top-x5"> <div class="text-center"> <button type="submit" class="rover-btn btn-block-xs rover-btn-primary js-wizard-next-section">Save & Continue</button> </div> </div> </div> </form> </div> </div> </div> </div>