<div class="row">
    <div class="medium-4 small-12 columns"><label> Full Name <span style="color:red;font-weight:bold;">*</span> [text* your-name] </label></div>
    <div class="medium-4 small-12 columns"><label> Date of Birth <span style="color:red;font-weight:bold;">*</span> [date* your-dob] </label></div>
    <div class="medium-4 small-12 columns"><label> Email <span style="color:red;font-weight:bold;">*</span> [email* your-email] </label></div>
</div>
<div class="row">
    <div class="medium-4 small-12 columns"><label> Your Mobile <span style="color:red;font-weight:bold;">*</span>[number* your-mobile] </label></div>
    <div class="medium-4 small-12 columns"><label> Your Phone<span style="color:red;font-weight:bold;">*</span> [number* your-phone] </label></div>
    <div class="medium-4 small-12 columns"><label> Home Address <span style="color:red;font-weight:bold;">*</span>[text* your-address] </label></div>
</div>
<div class="row">
    <div class="medium-4 small-12 columns"><label> I would apply for  ( Please tick relevant ) <span style="color:red;font-weight:bold;">*</span>
[select* your-applyfor "Citizenship" "ILR ( Indefinite Leave to Remain)" "Spouse visa extension" "N / A"] </label></div>
     <div class="medium-4 small-12 columns"><label> Current Job / study Any other relevant  [text* your-currentjob] </label></div>
   <div class="medium-4 small-12 columns"><label> Where did you hear about us? <span style="color:red;font-weight:bold;">* </span>   [select* how-hear "Google" "Whats message, Text message, Viber message" "Social media ( Facebook, Youtube" "Flyer (Door)" "Flyer (Mosque)" "Friend referral" "X-Student" "Road sign" "Shop banner" "Others"] </label></div>
</div>
<div class="row">
    <div class="medium-12 small-12 columns"><label> 
[checkbox* your-chekbox  "Please tick this box if you would like to receive* information about courses from eHouse Leeds."] </label></div>
</div>
<div class="row">
    <div class="medium-12 small-12 columns"><label>
[checkbox* your-chekbox2  "Please tick this box if you give us permission to use your picture in eHouse marketing material."] </label></div>
</div>
<h3 style="margin: 0px;">Terms & Conditions</h3>
<ul style="margin: 0px;">
<li>Course fee must be paid in advance or on the date of registration of the course.</li>
<li>Course cancellation or day (s) cancellation by Education House Leeds because of unseen reasons is not refundable. </li>
<li>Any student who abandons classes after the commencement of the course will not be entitled to refund of the fees paid.</li>
<li>Registration fee is non refundable but it is adjustable in the total fee of the course (s). </li>
</ul>
<p style="margin: 0px;">I, declare information I have given in this form is correct. I further certify that I have read, understood and agree to comply with the terms and conditions of the registration mentioned above.</p> 
[submit "Submit"]