Enter personal information:
[text firstnaem class:firstname placeholder "First Name"]
[text lastname class:lastname placeholder "Last Name"]
[date dateofbirth class:dobClass placeholder "Date of Birth"]
[text address class:address placeholder "Address"]
[text city class:city placeholder "City"]
[select menu-189 class:selectastate "Alabama" "Alaska" "Arizona" "Arkansas" "California" "Colorado" "Connecticut" "Delaware" "Florida" "Georgia" "Hawaii" "Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine" "Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri" "Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New York" "North Carolina" "North Dakota" "Ohio" "Oklahoma" "Oregon" "Pennsylvania" "Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah" "Vermont" "Virginia" "Washington" "West Virginia" "Wisconsin" "Wyoming"]
[text zipcode class:zipcode placeholder "Zip Code"]
Enter phone numbers:
[text homephone class:homephonenumber placeholder "Home Phone Number"]
[text workphone class:workphonenumber placeholder "Work Phone Number"]
[text cellphone class:cellphonenumber placeholder "Cell Phone Number"]
Number of children:
[text numchildren class:numchildren placeholder "Number of Children"]
[text childrenages class:agesofchildren placeholder "Ages of children"]
Have you every had a C-section?:
[radio hadcsection class:hadcsection use_label_element default:1 "Yes" "No"]
[text totalcsections class:totalcsections placeholder "If yes, how many?"]
For any pregnancy, did you deliver before 37 weeks?:
[text deliverbefore36 class:deliverbefore36 placeholder "Any pregnancy delivery before 37 weeks?"]
[textarea explainbirthbefore36 class:explainbirthbefore36 placeholder "If yes, explain in detail"]
[submit class:submitSurApp "Submit Application"]