<div class="row">
    <div class="medium-4 small-12 columns"><label> Full Name <span style="color:red;">*</span> [text* your-name] </label></div>
    <div class="medium-4 small-12 columns"><label> Date of Birth <span style="color:red;">*</span> [date* your-dob] </label></div>    
    <div class="medium-4 small-12 columns"><label> Email <span style="color:red;">*</span> [email* your-email] </label></div>
</div>
<div class="row">
    <div class="medium-4 small-12 columns"><label> Mobile no. <span style="color:red;">*</span> ( with country code ) [number* your-mobile] </label></div>
    <div class="medium-4 small-12 columns"><label> Your Age <span style="color:red;">*</span>[text* your-age] </label></div>
    <div class="medium-4 small-12 columns"><label>Latest Qualification <span style="color:red;">*</span> [text* your-qualification] </label></div>
</div>
<div class="row">
    <div class="medium-4 small-12 columns"><label> Study Gap <span style="color:red;">*</span> [text* your-study-gap] </label></div>
    <div class="medium-4 small-12 columns"><label> Marks % in latest Qualification <span style="color:red;">*</span>  [text* your-marks] </label></div>
    <div class="medium-4 small-12 columns"><label> Country of residence <span style="color:red;">*</span> 
[select* your-country "United Kingdom" "Canada" "Mexico" "United States"  "Afghanistan" "Albania" "Algeria" "American Samoa" "Andorra" "Angola" "Anguilla" "Antigua and Barbuda" "Argentina" "Armenia" "Armenia" "Aruba" "Australia" "Austria" "Azerbaijan" "Azerbaijan" "Bahamas" "Bahrain" "Bangladesh" "Barbados" "Belarus" "Belgium" "Belize" "Benin" "Bermuda" "Bhutan" "Bolivia" "Bonaire" "Bosnia and Herzegovina" "Botswana" "Bouvet Island (Bouvetoya)" "Brazil" "British Indian Ocean Territory (Chagos Archipelago)" "British Virgin Islands" "Brunei Darussalam" "Bulgaria" "Burkina Faso" "Burundi" "Cambodia" "Cameroon" "Cape Verde" "Cayman Islands" "Central African Republic" "Chad" "Chile" "China" "Christmas Island" "Cocos (Keeling) Islands" "Colombia" "Comoros" "Congo" "Congo" "Cook Islands" "Costa Rica" "Cote d'Ivoire" "Croatia" "Cuba" "Curaçao" "Cyprus" "Cyprus" "Czech Republic" "Denmark" "Djibouti" "Dominica" "Dominican Republic" "Ecuador" "Egypt" "El Salvador" "Equatorial Guinea" "Eritrea" "Estonia" "Ethiopia" "Falkland Islands (Malvinas)" "Faroe Islands" "Fiji" "Finland" "France" "French Guiana" "French Polynesia" "French Southern Territories" "Gabon" "Gambia" "Georgia" "Germany" "Ghana" "Gibraltar" "Greece" "Greenland" "Grenada" "Guadeloupe" "Guam" "Guatemala" "Guernsey" "Guinea" "Guinea-Bissau" "Guyana" "Haiti" "Heard Island and McDonald Islands" "Holy See (Vatican City State)" "Honduras" "Hong Kong" "Hungary" "Iceland" "India" "Indonesia" "Iran" "Iraq" "Ireland" "Isle of Man" "Israel" "Italy" "Jamaica" "Japan" "Jersey" "Jordan" "Kazakhstan" "Kazakhstan" "Kenya" "Kiribati" "Korea" "Korea" "Kuwait" "Kyrgyz Republic" "Lao People's Democratic Republic" "Latvia" "Lebanon" "Lesotho" "Liberia" "Libyan Arab Jamahiriya" "Liechtenstein" "Lithuania" "Luxembourg" "Macao" "Macedonia" "Madagascar" "Malawi" "Malaysia" "Maldives" "Mali" "Malta" "Marshall Islands" "Martinique" "Mauritania" "Mauritius" "Mayotte" "Micronesia" "Moldova" "Monaco" "Mongolia" "Montenegro" "Montserrat" "Morocco" "Mozambique" "Myanmar" "Namibia" "Nauru" "Nepal" "Netherlands" "Netherlands Antilles" "New Caledonia" "New Zealand" "Nicaragua" "Niger" "Nigeria" "Niue" "Norfolk Island" "Northern Mariana Islands" "Norway" "Oman" "Pakistan" "Palau" "Palestinian Territory" "Panama" "Papua New Guinea" "Paraguay" "Peru" "Philippines" "Pitcairn Islands" "Poland" "Portugal" "Puerto Rico" "Qatar" "Reunion" "Romania" "Russian Federation" "Rwanda" "Saint Barthelemy" "Saint Helena" "Saint Kitts and Nevis" "Saint Lucia" "Saint Martin" "Saint Pierre and Miquelon" "Saint Vincent and the Grenadines" "Samoa" "San Marino" "Sao Tome and Principe" "Saudi Arabia" "Senegal" "Serbia" "Seychelles" "Sierra Leone" "Singapore" "Sint Maarten (Netherlands)" "Slovakia (Slovak Republic)" "Slovenia" "Solomon Islands" "Somalia" "South Africa" "South Georgia & S. Sandwich Islands" "Spain" "Sri Lanka" "Sudan" "Suriname" "Svalbard & Jan Mayen Islands" "Swaziland" "Sweden" "Switzerland" "Syrian Arab Republic" "Taiwan" "Tajikistan" "Tanzania" "Thailand" "Timor-Leste" "Togo" "Tokelau" "Tonga" "Trinidad and Tobago" "Tunisia" "Turkey" "Turkey" "Turkmenistan" "Turks and Caicos Islands" "Tuvalu" "U.S. Virgin Islands" "U.S. Minor Outlying Islands" "Uganda" "Ukraine" "United Arab Emirates" "Uruguay" "Uzbekistan" "Vanuatu" "Venezuela" "Vietnam" "Wallis and Futuna" "Western Sahara" "Yemen" "Zambia" "Zimbabwe"]</label>
</div>
</div>
<div class="row">
    <div class="medium-12 small-12 columns"><label><span style="font-weight:bold;"> English Language Proficiency</span> <span style="color:red;">*</span>
[checkbox* your-lang "English is my First language" "IELTS" "TOEFL" "TOEIC" "Other"] </label></div>
</div>
<div class="row">
 <div class="medium-12 small-12 columns"><label><span style="font-weight:bold;"> Current position / Occupation</span> <span style="color:red;">*</span>
[checkbox* your-position "Employed" "Self-employed" "Student " "Unemployed"] </label></div>
</div>

<div class="row">
    <div class="medium-4 small-12 columns"><label>Professional position ( if employed ) [text your-professional-position] </label></div>
     <div class="medium-4 small-12 columns"><label>Company name ( if self-employed )  [text your-company] </label></div>
     <div class="medium-4 small-12 columns"><label>College / Uni name  (if student) [text your-college] </label></div>
</div>
<div class="row">
    <div class="medium-12 small-12 columns"><label>Current course of study (if student) [text your-current-course] </label></div>
</div>
<div class="row">
    <div class="medium-12 small-12 columns"><label><span style="font-weight:bold;"> Financial Sponsor</span> <span style="color:red;">*</span>
[checkbox* your-financial  "Parents" "Self" "Company" "Government" "Others"] </label></div>
</div>
<div class="row">
    <div class="medium-6 small-12 columns"><label> Have you applied UK visa in past 10 years ? <span style="color:red;">*</span>[radio your-applied label_first default:1 "Yes" "No"] </label></div>
</div>
<div class="row">
    <div class="medium-12 small-12 columns"><label> Where did you hear about us?  <span style="color:red;">*</span> [select* how-hear "Google" "Whats message, Text message, Viber message" "Social media ( Facebook, Youtube"  "Friend referral" "X-Student" "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 / training from eHouse UK. "] </label></div>
</div>
<h5 style="font-weight:bold;margin:0px;">Declaration</h5>
<p style=" margin-top: 0px;">I declare information I have given in this form is correct. I further certify that I will agree to comply with the terms and conditions of the registration if short listed. </p>
[submit "Submit"]