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<p>This application is to be completed by the following types of students currently enrolled in a post-graduate or graduate program and who are seeking a learning experience at Mercy Medical Center and MercyCare Community Physicians.</p><div class=\'form-group\'><label  class=\'control-label  \'>Student Type<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Resident\' required data-msg-required=\'Student Type is required.\' name=\'checkbox2\' id=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_1\' class=\'right\' data-export-label=\'Student_Type\' ><label for=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_1\'>Resident</label></div><div class=\'flow\'><input type=\'radio\' value=\'Medical School Graduate Program\' required data-msg-required=\'Student Type is required.\' name=\'checkbox2\' id=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_2\' class=\'right\' data-export-label=\'Student_Type\' ><label for=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_2\'>Medical School Graduate Program</label></div><div class=\'flow\'><input type=\'radio\' value=\'ARNP\' required data-msg-required=\'Student Type is required.\' name=\'checkbox2\' id=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_3\' class=\'right\' data-export-label=\'Student_Type\' ><label for=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_3\'>ARNP</label></div><div class=\'flow\'><input type=\'radio\' value=\'PA\' required data-msg-required=\'Student Type is required.\' name=\'checkbox2\' id=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_4\' class=\'right\' data-export-label=\'Student_Type\' ><label for=\'FormField2_44e9547a-96a5-499a-abc7-797a719db043_4\'>PA</label></div></fieldset></div></div></div><p>A written contract must be executed with your academic institution prior to the start of your learning experience. Please provide your school of attendance and expected graduation date.</p><div class=\'form-group\'><label for=\'FormField4_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>School<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField5_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Expected Graduation<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField5_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField5_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Expected Graduation is required.\' data-export-label=\'Expected_Graduation\'  placeholder=\'\'  />\
</div></div><hr><p><br></p><p><span style=\'font-size: 24px;\'><strong class=\'\'>Contact Information</strong></span></p><div class=\'form-group\'><label for=\'FormField8_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>First Name<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField9_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Middle Initial</label><div>\
<input type=\'text\' name=\'FormField9_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField9_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Middle_Initial\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField10_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Last Name<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField10_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField10_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Last Name is required.\' data-export-label=\'Last_Name\'  placeholder=\'\'  />\
</div></div>\
                <fieldset class=\'fb-fieldset \'>\
                    <legend class=\'fb-legend \'>Address</legend>\
                    \
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                    \
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                    <div class=\'row\'>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_City\'>City<span class=\'fb-required\'>*</span></label>\
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                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_State\'>State<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <select class=\'form-control\' name=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_State\' id=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_State\' autocomplete=\'region\' required=\'required\' data-msg-required=\'Address State is required.\' data-export-label=\'Address_State\' >\
                            <option value=\'\'>( Please Select )</option>\
                            <option value=\'AL\'>Alabama</option>\
                            <option value=\'AK\'>Alaska</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=\'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=\'OH\'>Ohio</option>\
                            <option value=\'OK\'>Oklahoma</option>\
                            <option value=\'OR\'>Oregon</option>\
                            <option value=\'PA\'>Pennsylvania</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=\'VA\'>Virginia</option>\
                            <option value=\'WA\'>Washington</option>\
                            <option value=\'WV\'>West Virginia</option>\
                            <option value=\'WI\'>Wisconsin</option>\
                            <option value=\'WY\'>Wyoming</option>\
                        </select>\
                    </div>\
                </div>\
                \
                        </div>\
                        <div class=\'col-sm-4\'>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label \' for=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_Zip\'>Zip<span class=\'fb-required\'>*</span></label>\
                    <div >\
                        <input class=\'form-control\' id=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_Zip\' name=\'FormField11_44e9547a-96a5-499a-abc7-797a719db043_Zip\' type=\'text\' data-export-label=\'Address_Zip\'  required data-msg-required=\'Address Zip is required.\' autocomplete=\'postal-code\' data-rule-zipCode=\'true\' />\
                    </div>\
                </div>\
                        </div>\
                    </div>\
                </fieldset><div class=\'form-group\'><label for=\'FormField12_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Phone<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField12_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField12_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Phone is required.\' data-export-label=\'Phone\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField13_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Email<span class=\'fb-required\'>*</span></label><div><input type=\'email\' name=\'FormField13_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField13_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Email is required.\' data-export-label=\'Email\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField14_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Date of Birth<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField14_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField14_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Date of Birth is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Date_of_Birth\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField15_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Last four digits of Social Security Number</label><div>\
<input type=\'text\' name=\'FormField15_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField15_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Last_4_SSN\'  placeholder=\'\'  />\
</div></div><hr><p><br></p><p><span style=\'font-size: 24px;\'><strong class=\'\'>Residents Only</strong></span></p><p>Please provide the following:</p><div class=\'form-group\'><label for=\'FormField17_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Iowa License Number</label><div>\
<input type=\'text\' name=\'FormField17_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField17_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Iowa_License_Number\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField18_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Expiration Date</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField18_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField18_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'License_Expiration_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField19_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Iowa Controlled Substances Registration Number (CSA)</label><div>\
<input type=\'text\' name=\'FormField19_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField19_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'CSA\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField20_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Expiration Date</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField20_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField20_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'CSA_Expiration_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField21_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Federal Drug Enforcement Administration (DEA)</label><div>\
<input type=\'text\' name=\'FormField21_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField21_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'DEA\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField22_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Expiration Date</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField22_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField22_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'DEA_Expiration_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><hr><p><br></p><p><span style=\'font-size: 24px;\'><strong class=\'\'>Emergency Contacts</strong></span></p><p>We are committed to your safety. Please provide two Emergency Contacts in the event we are unable to reach your first. Thank you.</p><div class=\'form-group\'><label for=\'FormField24_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Name<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField25_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Cell Phone<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField25_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField25_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Cell Phone is required.\' data-export-label=\'Cell_Phone_1\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField26_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Relationship<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField26_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField26_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Relationship is required.\' data-export-label=\'Relationship_1\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField27_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Name<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField27_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField27_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Name is required.\' data-export-label=\'Name_2\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField28_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Cell Phone<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField28_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField28_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Cell Phone is required.\' data-export-label=\'Cell_Phone_2\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField29_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Relationship<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField29_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField29_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Relationship is required.\' data-export-label=\'Relationship_2\'  placeholder=\'\'  />\
</div></div><hr><p><br></p><p><span style=\'font-size: 24px;\'><strong class=\'\'>Learning Experience Being Requested:</strong></span></p><div class=\'form-group\'><label for=\'FormField31_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Responsible Precepting Physician, NP or PA:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField31_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField31_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Responsible Precepting Physician, NP or PA: is required.\' data-export-label=\'Preceptor\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField32_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Precepting Department or Clinic:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField32_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField32_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Precepting Department or Clinic: is required.\' data-export-label=\'Dept_Clinic\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField33_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Start Date:<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField33_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField33_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Start Date: is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Start_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField34_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>End Date:<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField34_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField34_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'End Date: is required.\' data-format=\'mm/dd/yy\' data-export-label=\'End_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><hr><p><br></p><p><span style=\'font-size: 24px;\'><strong class=\'\'>Criminal History:</strong></span></p><p>Have you ever been convicted of, or pleaded guilty to a criminal offense (misdemeanor or felony)? Falsification of this or any information on this application is grounds for immediate dismissal. A conviction does not necessarily disqualify you from the learning experience. Acceptance of application will be made on a case-by-case basis.</p><div class=\'form-group\'><label  class=\'control-label  \'>Criminal history:<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\' required data-msg-required=\'Criminal history: is required.\' name=\'checkbox36\' id=\'FormField36_44e9547a-96a5-499a-abc7-797a719db043_1\' class=\'right\' data-export-label=\'Criminal_history\' ><label for=\'FormField36_44e9547a-96a5-499a-abc7-797a719db043_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\' required data-msg-required=\'Criminal history: is required.\' name=\'checkbox36\' id=\'FormField36_44e9547a-96a5-499a-abc7-797a719db043_2\' class=\'right\' data-export-label=\'Criminal_history\' ><label for=\'FormField36_44e9547a-96a5-499a-abc7-797a719db043_2\'>No</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField37_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Explanation:</label><div>\
<textarea rows=\'10\' name=\'FormField37_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField37_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control textarea-medium\'   data-export-label=\'Explanation\'  placeholder=\'\'></textarea>\
</div></div><hr><p><br></p><p><span style=\'font-size: 24px;\'><strong class=\'\'>I Agree</strong></span></p><div class=\'form-group\'><label  class=\'control-label  \'>I hereby certify that the information I submit in this application is complete and correct.<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><div class=\'flow\'><input type=\'radio\' value=\'I agree\' required data-msg-required=\'I hereby certify that the information I submit in this application is complete and correct. is required.\' name=\'checkbox39\' id=\'FormField39_44e9547a-96a5-499a-abc7-797a719db043_1\' class=\'right\' data-export-label=\'Certify\' ><label for=\'FormField39_44e9547a-96a5-499a-abc7-797a719db043_1\'>I agree</label></div></div></div></div><p>My electronic signature will constitute my &quot;original&quot; signature.</p><div class=\'form-group\'><label for=\'FormField40_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Signature<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField40_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField40_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Signature is required.\' data-export-label=\'Signature\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField43_44e9547a-96a5-499a-abc7-797a719db043\' class=\'control-label  \'>Date<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField43_44e9547a-96a5-499a-abc7-797a719db043\' id=\'FormField43_44e9547a-96a5-499a-abc7-797a719db043\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'Date is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div>\
\
<div id=\'form-errors\' class=\'alert alert-danger fade in\' role=\'alert\' style=\'display:none\'></div>\
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