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Rev 22643 Rev 22644
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			</div>
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			</div>
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			<div class="col-lg-2 form-group">
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			<div class="col-lg-2 form-group">
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			   	<input placeholder="Last Name" id="lastName" name="lastName" type="text" value="" class="form-control input-sm">
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			   	<input placeholder="Last Name" id="lastName" name="lastName" type="text" value="" class="form-control input-sm">
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			</div>
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			</div>
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			<div class="col-lg-3 form-group">
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			<div class="col-lg-3 form-group">
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				<input placeholder="Email" id="email" name="email" type="text" value="" class="form-control input-sm">
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				<input placeholder="Email*" id="email" name="email" type="text" value="" class="form-control input-sm">
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			</div>
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			</div>
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			<div class="col-lg-3 form-group">
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			<div class="col-lg-3 form-group">
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				<input placeholder = "Phone Number" id="phone" name="phone" type="text" value="" class="form-control phone input-sm">
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				<input placeholder = "Phone Number*" id="phone" name="phone" type="text" value="" class="form-control phone input-sm">
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			</div>
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			</div>
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			<div class="col-lg-2 form-group">
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			<div class="col-lg-2 form-group">
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				<input placeholder = "Date Of Birth" id="dateOfBirth" name="dateOfBirth" type="date" value="" class="form-control input-sm">
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				<input placeholder = "Date Of Birth*" id="dateOfBirth" name="dateOfBirth" type="date" value="" class="form-control input-sm">
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			</div>
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			</div>
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		</div>
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		</div>
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		<div class = "row">
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		<div class = "row">
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			<div class="col-lg-4 form-group">
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			<div class="col-lg-4 form-group">