<%@ Control Language="VB" AutoEventWireup="false" CodeFile="PreRegistration.ascx.vb" Inherits="Controls_PreRegistration" %>
<div id="centerBody">
    <h1>
        Request for Follow-Up</h1>
    <p>
           <asp:Panel ID="pnlMissing" runat="server" DefaultButton="btnSubmit">
        <!-- start PanelSubpanelBlue template -->
        <div id="blue" class="roundedTopLeft">
            <div id="blue" class="roundedTopRight">
                <div id="blue" class="roundedBotRight">
                    <div id="blue" class="roundedBotLeft">
                        <h2>
                            Request</h2>
                        <div class="solidRoundedBlue">
                            <div class="solidRoundedTop">
                                <div>
                                </div>
                            </div>
                            <div id="solidRoundedContent">
                                <div id="form" class="noHeader">
                                    <div>
                                        <span class="orange">(* Required field)</span><br />
                                        <br />
                                    </div>
                                    <!-- begin content area -->
                                    <table style="left: 150px; padding-left: 100px;" cellpadding="3" cellspacing="3">
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> Last Name:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtLastName" runat="server" style="padding-left:1px"/>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;width:100px;">
                                                <asp:RequiredFieldValidator ID="vldLastNameRequired" runat="server" ControlToValidate="txtLastName" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> First Name:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtFirstName" runat="server" style="padding-left:1px"/>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldFirstNameRequired" runat="server" ControlToValidate="txtFirstName" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> Street Address:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtStreet" runat="server" style="padding-left:1px"></asp:TextBox>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldStreetRequired" runat="server" ControlToValidate="txtStreet" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                Apartment Number:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtApt" runat="server" style="padding-left:1px"></asp:TextBox>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                &nbsp;
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> City:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtCity" runat="server" style="padding-left:1px"></asp:TextBox>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldCityRequired" runat="server" ControlToValidate="txtCity" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> State:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:DropDownList ID="ddlState" runat="server">
                                                </asp:DropDownList>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldStateRequired" runat="server" ControlToValidate="ddlState" Display="Dynamic" InitialValue="" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> Zip Code:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtZip" runat="server" style="padding-left:1px"></asp:TextBox>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldZipRequired" runat="server" ControlToValidate="txtZip" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                                <asp:RegularExpressionValidator ID="vldZipRegEx" runat="server" ControlToValidate="txtZip" Display="Dynamic" ErrorMessage="Invalid Format" ValidationExpression="\d{5}(-\d{4})?" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RegularExpressionValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> Phone:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtPhone" runat="server" style="padding-left:1px"/>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldPhoneRequired" runat="server" ControlToValidate="txtPhone" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                                <asp:RegularExpressionValidator ID="vldPhoneRegEx" runat="server" ControlToValidate="txtPhone" Display="Dynamic" ErrorMessage="Invalid Format" ValidationExpression="((\(\d{3}\) ?)|(\d{3}-))?\d{3}-\d{4}|(\d{10})" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RegularExpressionValidator>
                                            </td>
                                        </tr>
                                        <tr>
                                            <td style="text-align: right; background-color: #D9E4EE;">
                                                <span class="orange">*</span> E-Mail:
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:TextBox ID="txtEmail" runat="server" style="padding-left:1px"/>
                                            </td>
                                            <td style="text-align: left; background-color: #D9E4EE;">
                                                <asp:RequiredFieldValidator ID="vldEmailRequired" runat="server" ControlToValidate="txtEmail" Display="Dynamic" ErrorMessage="Required" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RequiredFieldValidator>
                                                <asp:RegularExpressionValidator ID="vldEmailRegEx" runat="server" ControlToValidate="txtEmail" Display="Dynamic" ErrorMessage="Invalid Format" ValidationExpression="\w+([-+.']\w+)*@\w+([-.]\w+)*\.\w+([-.]\w+)*" CssClass="orange" ForeColor="" SetFocusOnError="True"></asp:RegularExpressionValidator>
                                            </td>
                                        </tr>
                                        
                                        <tr>
                                            <td style="text-align: center; background-color: #D9E4EE;" colspan="3">
                                                <br />
                                                <asp:Button ID="btnSubmit" runat="server" Text="Submit" />
                                            </td>
                                        </tr>
                                    </table>
                                    <!-- end content area -->
                                </div>
                            </div>
                            <div class="solidRoundedBot">
                                <div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
        </div>
        <!-- end PanelSubpanelBlue template -->
    </asp:Panel>
</div>