Forms

<div class="ds-block ds-block--narrow">
   
    <h2 style="text-align: center;">Ask a question</h2>
    <p style="text-align: center;">We will respond by the next business day. <br>Please note that fields containing an asterisk (*) are compulsory.</p>

    <form class="ds-form ds-form--full-width" action="">
        
        <div class="ds-grid">
            
            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="firstname">First name <abbr class="ds-label__required" title="required">*</abbr></label>
                    <input class="ds-text-input" type="text" id="firstname" placeholder="" required/>
                </div>

            </div>

            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="surname">Family name <abbr class="ds-label__required" title="required">*</abbr></label>
                    <input class="ds-text-input" type="text" id="surname" placeholder="" required/>
                </div>

            </div>
    
            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="email">Email address <abbr class="ds-label__required" title="required">*</abbr></label>
                    <input class="ds-text-input" type="email" id="email" placeholder="example@mail.com" required/>
                </div>

            </div>

            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label ds-label__required" for="mobile">Mobile number <abbr class="ds-label__required" title="required">*</abbr></label>
                    <input class="ds-text-input" type="tel" id="mobile" placeholder="" required/>
                </div>

            </div>

                
            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="name">Country of residence  <abbr class="ds-label__required" title="required">*</abbr></label>
                
                    <select class="ds-select" required>
                        <option value="">---</option>
                        <option value="option-2">Afghanistan</option>
                        <option value="option-3">Albania</option>
                        <option value="option-4">Algeria</option>
                    </select>
                </div>

            </div>

            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="name">Country of nationality</label>
                
                    <select class="ds-select">
                        <option value="">---</option>
                        <option value="option-2">Afghanistan</option>
                        <option value="option-3">Albania</option>
                        <option value="option-4">Algeria</option>
                    </select>
                </div>

            </div>

                
            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="name">Level of study</label>

                    <select class="ds-select hobsons-field" data-placeholder="Level of study" name="levelOfStudy" id="levelOfStudy" required>
                        <option selected="selected" value="">---</option>
                        <option value="cross-institution-postgraduate">Cross Institution Postgraduate</option>
                        <option value="cross-institution-undergraduate">Cross Institution Undergraduate</option>
                        <option value="non-award-course">Non-award Course</option>
                        <option value="postgraduate">Postgraduate</option>
                        <option value="postgraduate-research">Postgraduate Research</option>
                        <option value="study-abroad">Study Abroad</option>
                        <option value="undergraduate">Undergraduate</option>
                    </select>

                </div>

            </div>
            
            <div class="ds-grid__col-6">

                <div class="ds-form-group">
                    <label class="ds-label" for="name">Course  <abbr class="ds-label__required" title="required">*</abbr></label>
                
                    <select class="ds-select" required>
                        <option value="">---</option>
                        <option value="option-2">Undergraduate</option>
                        <option value="option-3">Non-award course</option>
                    </select>
                </div>

            </div>

            <div class="ds-grid__col-12">

                <div class="ds-form-group">
                    <label class="ds-label" for="questions">Questions</label>
                    <textarea class="ds-textarea" id="questions" rows="8" placeholder=""></textarea>
                </div>

                <div class="ds-form-group">
                    <input type="submit" value="Submit">
                </div>

            </div>

        </div>

    </form>

    <p>By completing this form you give consent for La Trobe University to contact you for marketing purposes. If at any stage you no longer wish to be contacted, simply choose unsubscribe in any of our emails. Read more about <a href="https://www.latrobe.edu.au/privacy">Privacy at La Trobe University</a>.</p>
 
</div>

<form id="form_email_1131822" enctype="multipart/form-data" action="https://www.latrobe.edu.au/ds/samples/form-test/_nocache" method="post">
	<input type="hidden" name="SQ_FORM_1131822_PAGE" value="1" class="sq-form-field" id="SQ_FORM_1131822_PAGE">
		<input type="hidden" name="form_email_1131822_referral_url" value="https://www.latrobe.edu.au/_cmsmod/">
			<div class="sq-form-required-field-note">Required fields are marked with an asterisk (
				<abbr class="sq-form-required-field" title="required">*</abbr>).
			</div>
			<div class="sq-form-unattached">
				<div class="sq-form-question sq-form-question-text ">
					<label class="sq-form-question-title" for="q1131822_q9">Text</label>
					<em class="sq-form-question-note">This is a note</em>
					<div class="sq-form-question-answer">
						<input type="text" name="q1131822:q9" value="" size="30" maxlength="300" placeholder="Placeholder" id="q1131822_q9" class="sq-form-field">
						</div>
					</div>
					<div class="sq-form-question sq-form-question-email-address sq-form-question-error">
						<label class="sq-form-question-title" for="q1131822_q3">Email address 
							<abbr class="sq-form-required-field" title="required">*</abbr>
						</label>
						<div class="sq-form-question-answer">
							<input type="text" name="q1131822:q3" value="" size="30" maxlength="300" id="q1131822_q3" class="sq-form-field">
							</div>
							<p id="error_1131822_q3" class="sq-form-error">This field is required. Please enter a value.</p>
						</div>
						<div class="sq-form-question sq-form-question-password sq-form-question-error">
							<fieldset>
								<legend class="sq-form-question-title">Password 
									<abbr class="sq-form-required-field" title="required">*</abbr>
								</legend>
								<div class="sq-form-question-answer">
									<div class="sq-form-question-password">
										<label class="sq-form-question-title" for="q1131822_q7">Password</label>
										<div class="sq-form-question-password-answer">
											<input type="password" name="q1131822:q7" value="" size="30" maxlength="30" id="q1131822_q7" class="sq-form-field" autocomplete="new-password">
											</div>
										</div>
										<div class="sq-form-question-password-verify">
											<label class="sq-form-question-title" for="q1131822_q7_2">Confirm Password</label>
											<div class="sq-form-question-password-verify-answer">
												<input type="password" name="q1131822:q7_2" value="" size="30" maxlength="30" id="q1131822_q7_2" class="sq-form-field" autocomplete="new-password">
												</div>
											</div>
										</div>
										<p id="error_1131822_q7" class="sq-form-error">Password must be no less than 2 characters</p>
									</fieldset>
								</div>
								<div class="sq-form-question sq-form-question-select ">
									<label class="sq-form-question-title" for="q1131822_q8">Select</label>
									<div class="sq-form-question-answer">
										<select name="q1131822:q8" id="q1131822_q8" class="sq-form-field">
											<option value="Value1" selected="selected">Value 1</option>
											<option value="Value2">Value 2</option>
										</select>
									</div>
								</div>
								<div class="sq-form-question sq-form-question-country ">
									<label class="sq-form-question-title" for="q1131822_q1">Country</label>
									<div class="sq-form-question-answer">
										<select name="q1131822:q1" id="q1131822_q1" class="sq-form-field">
											<option value="af" selected="selected">Afghanistan</option>
											<option value="ax">Åland Islands</option>
											<option value="al">Albania</option>
											<option value="dz">Algeria</option>
											<option value="as">American Samoa</option>
											<option value="ad">Andorra</option>
											<option value="ao">Angola</option>
											<option value="ai">Anguilla</option>
											<option value="aq">Antarctica</option>
											<option value="ag">Antigua and Barbuda</option>
											<option value="ar">Argentina</option>
											<option value="am">Armenia</option>
											<option value="aw">Aruba</option>
											<option value="au">Australia</option>
											<option value="at">Austria</option>
											<option value="az">Azerbaijan</option>
											<option value="bs">Bahamas</option>
											<option value="bh">Bahrain</option>
											<option value="bd">Bangladesh</option>
											<option value="bb">Barbados</option>
											<option value="by">Belarus</option>
											<option value="be">Belgium</option>
											<option value="bz">Belize</option>
											<option value="bj">Benin</option>
											<option value="bm">Bermuda</option>
											<option value="bt">Bhutan</option>
											<option value="bo">Bolivia</option>
											<option value="bq">Bonaire, Sint Eustatius and Saba</option>
											<option value="ba">Bosnia and Herzegovina</option>
											<option value="bw">Botswana</option>
											<option value="bv">Bouvet Island</option>
											<option value="br">Brazil</option>
											<option value="io">British Indian Ocean Territory</option>
											<option value="bn">Brunei Darussalam</option>
											<option value="bg">Bulgaria</option>
											<option value="bf">Burkina Faso</option>
											<option value="bi">Burundi</option>
											<option value="kh">Cambodia</option>
											<option value="cm">Cameroon</option>
											<option value="ca">Canada</option>
											<option value="cv">Cape Verde</option>
											<option value="ky">Cayman Islands</option>
											<option value="cf">Central African Republic</option>
											<option value="td">Chad</option>
											<option value="cl">Chile</option>
											<option value="cn">China</option>
											<option value="cx">Christmas Island</option>
											<option value="cc">Cocos (Keeling) Islands</option>
											<option value="co">Colombia</option>
											<option value="km">Comoros</option>
											<option value="cg">Congo</option>
											<option value="cd">Democratic Republic of the Congo</option>
											<option value="ck">Cook Islands</option>
											<option value="cr">Costa Rica</option>
											<option value="ci">Côte d'Ivoire (Ivory Coast)</option>
											<option value="hr">Croatia</option>
											<option value="cu">Cuba</option>
											<option value="cw">Curaçao</option>
											<option value="cy">Cyprus</option>
											<option value="cz">Czech Republic</option>
											<option value="dk">Denmark</option>
											<option value="dj">Djibouti</option>
											<option value="dm">Dominica</option>
											<option value="do">Dominican Republic</option>
											<option value="ec">Ecuador</option>
											<option value="eg">Egypt</option>
											<option value="sv">El Salvador</option>
											<option value="gq">Equatorial Guinea</option>
											<option value="er">Eritrea</option>
											<option value="ee">Estonia</option>
											<option value="et">Ethiopia</option>
											<option value="fk">Falkland Islands (Malvinas)</option>
											<option value="fo">Faroe Islands</option>
											<option value="fj">Fiji</option>
											<option value="fi">Finland</option>
											<option value="fr">France</option>
											<option value="gf">French Guiana</option>
											<option value="pf">French Polynesia</option>
											<option value="tf">French Southern Territories</option>
											<option value="ga">Gabon</option>
											<option value="gm">Gambia</option>
											<option value="ge">Georgia</option>
											<option value="de">Germany</option>
											<option value="gh">Ghana</option>
											<option value="gi">Gibraltar</option>
											<option value="gr">Greece</option>
											<option value="gl">Greenland</option>
											<option value="gd">Grenada</option>
											<option value="gp">Guadeloupe</option>
											<option value="gu">Guam</option>
											<option value="gt">Guatemala</option>
											<option value="gg">Guernsey</option>
											<option value="gn">Guinea</option>
											<option value="gw">Guinea-Bissau</option>
											<option value="gy">Guyana</option>
											<option value="ht">Haiti</option>
											<option value="hm">Heard Island and McDonald Islands</option>
											<option value="va">Holy See (Vatican City State)</option>
											<option value="hn">Honduras</option>
											<option value="hk">Hong Kong</option>
											<option value="hu">Hungary</option>
											<option value="is">Iceland</option>
											<option value="in">India</option>
											<option value="id">Indonesia</option>
											<option value="ir">Iran</option>
											<option value="iq">Iraq</option>
											<option value="ie">Ireland</option>
											<option value="im">Isle of Man</option>
											<option value="il">Israel</option>
											<option value="it">Italy</option>
											<option value="jm">Jamaica</option>
											<option value="jp">Japan</option>
											<option value="je">Jersey</option>
											<option value="jo">Jordan</option>
											<option value="kz">Kazakhstan</option>
											<option value="ke">Kenya</option>
											<option value="ki">Kiribati</option>
											<option value="kp">North Korea</option>
											<option value="kr">South Korea</option>
											<option value="kw">Kuwait</option>
											<option value="kg">Kyrgyzstan</option>
											<option value="la">Laos</option>
											<option value="lv">Latvia</option>
											<option value="lb">Lebanon</option>
											<option value="ls">Lesotho</option>
											<option value="lr">Liberia</option>
											<option value="ly">Libya</option>
											<option value="li">Liechtenstein</option>
											<option value="lt">Lithuania</option>
											<option value="lu">Luxembourg</option>
											<option value="mo">Macao</option>
											<option value="mk">Former Yugoslav Republic of Macedonia</option>
											<option value="mg">Madagascar</option>
											<option value="mw">Malawi</option>
											<option value="my">Malaysia</option>
											<option value="mv">Maldives</option>
											<option value="ml">Mali</option>
											<option value="mt">Malta</option>
											<option value="mh">Marshall Islands</option>
											<option value="mq">Martinique</option>
											<option value="mr">Mauritania</option>
											<option value="mu">Mauritius</option>
											<option value="yt">Mayotte</option>
											<option value="mx">Mexico</option>
											<option value="fm">Federated States of Micronesia</option>
											<option value="md">Republic of Moldova</option>
											<option value="mc">Monaco</option>
											<option value="mn">Mongolia</option>
											<option value="me">Montenegro</option>
											<option value="ms">Montserrat</option>
											<option value="ma">Morocco</option>
											<option value="mz">Mozambique</option>
											<option value="mm">Myanmar (Burma)</option>
											<option value="na">Namibia</option>
											<option value="nr">Nauru</option>
											<option value="np">Nepal</option>
											<option value="nl">Netherlands</option>
											<option value="nc">New Caledonia</option>
											<option value="nz">New Zealand</option>
											<option value="ni">Nicaragua</option>
											<option value="ne">Niger</option>
											<option value="ng">Nigeria</option>
											<option value="nu">Niue</option>
											<option value="nf">Norfolk Island</option>
											<option value="mp">Northern Mariana Islands</option>
											<option value="no">Norway</option>
											<option value="om">Oman</option>
											<option value="pk">Pakistan</option>
											<option value="pw">Palau</option>
											<option value="ps">Palestine</option>
											<option value="pa">Panama</option>
											<option value="pg">Papua New Guinea</option>
											<option value="py">Paraguay</option>
											<option value="pe">Peru</option>
											<option value="ph">Philippines</option>
											<option value="pn">Pitcairn</option>
											<option value="pl">Poland</option>
											<option value="pt">Portugal</option>
											<option value="pr">Puerto Rico</option>
											<option value="qa">Qatar</option>
											<option value="re">Réunion</option>
											<option value="ro">Romania</option>
											<option value="ru">Russian Federation</option>
											<option value="rw">Rwanda</option>
											<option value="bl">Saint Barthélemy</option>
											<option value="sh">Saint Helena, Ascension and Tristan da Cunha</option>
											<option value="kn">Saint Kitts and Nevis</option>
											<option value="lc">Saint Lucia</option>
											<option value="mf">Saint Martin (French part)</option>
											<option value="pm">Saint Pierre and Miquelon</option>
											<option value="vc">Saint Vincent and the Grenadines</option>
											<option value="ws">Samoa</option>
											<option value="sm">San Marino</option>
											<option value="st">Sao Tome and Principe</option>
											<option value="sa">Saudi Arabia</option>
											<option value="sn">Senegal</option>
											<option value="rs">Serbia</option>
											<option value="sc">Seychelles</option>
											<option value="sl">Sierra Leone</option>
											<option value="sg">Singapore</option>
											<option value="sx">Sint Maarten (Dutch part)</option>
											<option value="sk">Slovakia</option>
											<option value="si">Slovenia</option>
											<option value="sb">Solomon Islands</option>
											<option value="so">Somalia</option>
											<option value="za">South Africa</option>
											<option value="gs">South Georgia and the South Sandwich Islands</option>
											<option value="ss">South Sudan</option>
											<option value="es">Spain</option>
											<option value="lk">Sri Lanka</option>
											<option value="sd">Sudan</option>
											<option value="sr">Suriname</option>
											<option value="sj">Svalbard and Jan Mayen</option>
											<option value="sz">Swaziland</option>
											<option value="se">Sweden</option>
											<option value="ch">Switzerland</option>
											<option value="sy">Syrian Arab Republic</option>
											<option value="tw">Taiwan</option>
											<option value="tj">Tajikistan</option>
											<option value="tz">Tanzania</option>
											<option value="th">Thailand</option>
											<option value="tl">Timor-Leste (East Timor)</option>
											<option value="tg">Togo</option>
											<option value="tk">Tokelau</option>
											<option value="to">Tonga</option>
											<option value="tt">Trinidad and Tobago</option>
											<option value="tn">Tunisia</option>
											<option value="tr">Turkey</option>
											<option value="tm">Turkmenistan</option>
											<option value="tc">Turks and Caicos Islands</option>
											<option value="tv">Tuvalu</option>
											<option value="ug">Uganda</option>
											<option value="ua">Ukraine</option>
											<option value="ae">United Arab Emirates</option>
											<option value="gb">United Kingdom</option>
											<option value="us">United States</option>
											<option value="um">United States Minor Outlying Islands</option>
											<option value="uy">Uruguay</option>
											<option value="uz">Uzbekistan</option>
											<option value="vu">Vanuatu</option>
											<option value="ve">Venezuela</option>
											<option value="vn">Viet Nam</option>
											<option value="vg">British Virgin Islands</option>
											<option value="vi">U.S. Virgin Islands</option>
											<option value="wf">Wallis and Futuna</option>
											<option value="eh">Western Sahara</option>
											<option value="ye">Yemen</option>
											<option value="zm">Zambia</option>
											<option value="zw">Zimbabwe</option>
										</select>
									</div>
								</div>
								<div class="sq-form-question sq-form-question-numeric ">
									<label class="sq-form-question-title" for="q1131822_q5">Numeric field</label>
									<div class="sq-form-question-answer">
										<input type="text" name="q1131822:q5" value="" size="30" maxlength="300" id="q1131822_q5" class="sq-form-field">
										</div>
									</div>
									<div class="sq-form-question sq-form-question-datetime sq-form-question-error">
										<fieldset>
											<legend class="sq-form-question-title">Date time 
												<abbr class="sq-form-required-field" title="required">*</abbr>
											</legend>
											<div class="sq-form-question-answer">
												<script type="text/javascript">
		//
													<![CDATA[
			if (typeof adjustDate != "function") {
				// function to enable + and - keys on a field
				adjustDate = function(input, evt)
				{
					var key = evt.keyCode;
					var value = parseInt(input.value * 1);
					if (key == 107 || key == 109) {
						value += (key == 109)?-1:1;
						if (value != 0) {
							input.value = value;
						}
						event.returnValue = false;
						event.cancelBubble = true;
						return false;
					}
				}
			}
		//]]>
												</script>
												<input type="hidden" name="q1131822_q2_show" value="dmyhis">
													<label for="q1131822_q2_value_d">Day</label>
													<select name="q1131822_q2_value[d]" id="q1131822_q2_value_d" class="sq-form-field">
														<option value="--"></option>
														<option value="1">1</option>
														<option value="2">2</option>
														<option value="3">3</option>
														<option value="4">4</option>
														<option value="5">5</option>
														<option value="6">6</option>
														<option value="7">7</option>
														<option value="8">8</option>
														<option value="9">9</option>
														<option value="10">10</option>
														<option value="11">11</option>
														<option value="12">12</option>
														<option value="13">13</option>
														<option value="14">14</option>
														<option value="15">15</option>
														<option value="16">16</option>
														<option value="17">17</option>
														<option value="18">18</option>
														<option value="19">19</option>
														<option value="20">20</option>
														<option value="21">21</option>
														<option value="22">22</option>
														<option value="23">23</option>
														<option value="24">24</option>
														<option value="25">25</option>
														<option value="26">26</option>
														<option value="27">27</option>
														<option value="28">28</option>
														<option value="29">29</option>
														<option value="30">30</option>
														<option value="31">31</option>
													</select>
													<label for="q1131822_q2_value_m">Month</label>
													<select name="q1131822_q2_value[m]" id="q1131822_q2_value_m" class="sq-form-field">
														<option value="--"></option>
														<option value="1">Jan</option>
														<option value="2">Feb</option>
														<option value="3">Mar</option>
														<option value="4">Apr</option>
														<option value="5">May</option>
														<option value="6">Jun</option>
														<option value="7">Jul</option>
														<option value="8">Aug</option>
														<option value="9">Sep</option>
														<option value="10">Oct</option>
														<option value="11">Nov</option>
														<option value="12">Dec</option>
													</select>
													<label for="q1131822_q2_value_y">Year</label>
													<select name="q1131822_q2_value[y]" id="q1131822_q2_value_y" class="sq-form-field">
														<option value="--"></option>
														<option value="1900">1900</option>
														<option value="1901">1901</option>
														<option value="1902">1902</option>
														<option value="1903">1903</option>
														<option value="1904">1904</option>
														<option value="1905">1905</option>
														<option value="1906">1906</option>
														<option value="1907">1907</option>
														<option value="1908">1908</option>
														<option value="1909">1909</option>
														<option value="1910">1910</option>
														<option value="1911">1911</option>
														<option value="1912">1912</option>
														<option value="1913">1913</option>
														<option value="1914">1914</option>
														<option value="1915">1915</option>
														<option value="1916">1916</option>
														<option value="1917">1917</option>
														<option value="1918">1918</option>
														<option value="1919">1919</option>
														<option value="1920">1920</option>
														<option value="1921">1921</option>
														<option value="1922">1922</option>
														<option value="1923">1923</option>
														<option value="1924">1924</option>
														<option value="1925">1925</option>
														<option value="1926">1926</option>
														<option value="1927">1927</option>
														<option value="1928">1928</option>
														<option value="1929">1929</option>
														<option value="1930">1930</option>
														<option value="1931">1931</option>
														<option value="1932">1932</option>
														<option value="1933">1933</option>
														<option value="1934">1934</option>
														<option value="1935">1935</option>
														<option value="1936">1936</option>
														<option value="1937">1937</option>
														<option value="1938">1938</option>
														<option value="1939">1939</option>
														<option value="1940">1940</option>
														<option value="1941">1941</option>
														<option value="1942">1942</option>
														<option value="1943">1943</option>
														<option value="1944">1944</option>
														<option value="1945">1945</option>
														<option value="1946">1946</option>
														<option value="1947">1947</option>
														<option value="1948">1948</option>
														<option value="1949">1949</option>
														<option value="1950">1950</option>
														<option value="1951">1951</option>
														<option value="1952">1952</option>
														<option value="1953">1953</option>
														<option value="1954">1954</option>
														<option value="1955">1955</option>
														<option value="1956">1956</option>
														<option value="1957">1957</option>
														<option value="1958">1958</option>
														<option value="1959">1959</option>
														<option value="1960">1960</option>
														<option value="1961">1961</option>
														<option value="1962">1962</option>
														<option value="1963">1963</option>
														<option value="1964">1964</option>
														<option value="1965">1965</option>
														<option value="1966">1966</option>
														<option value="1967">1967</option>
														<option value="1968">1968</option>
														<option value="1969">1969</option>
														<option value="1970">1970</option>
														<option value="1971">1971</option>
														<option value="1972">1972</option>
														<option value="1973">1973</option>
														<option value="1974">1974</option>
														<option value="1975">1975</option>
														<option value="1976">1976</option>
														<option value="1977">1977</option>
														<option value="1978">1978</option>
														<option value="1979">1979</option>
														<option value="1980">1980</option>
														<option value="1981">1981</option>
														<option value="1982">1982</option>
														<option value="1983">1983</option>
														<option value="1984">1984</option>
														<option value="1985">1985</option>
														<option value="1986">1986</option>
														<option value="1987">1987</option>
														<option value="1988">1988</option>
														<option value="1989">1989</option>
														<option value="1990">1990</option>
														<option value="1991">1991</option>
														<option value="1992">1992</option>
														<option value="1993">1993</option>
														<option value="1994">1994</option>
														<option value="1995">1995</option>
														<option value="1996">1996</option>
														<option value="1997">1997</option>
														<option value="1998">1998</option>
														<option value="1999">1999</option>
														<option value="2000">2000</option>
														<option value="2001">2001</option>
														<option value="2002">2002</option>
														<option value="2003">2003</option>
														<option value="2004">2004</option>
														<option value="2005">2005</option>
														<option value="2006">2006</option>
														<option value="2007">2007</option>
														<option value="2008">2008</option>
														<option value="2009">2009</option>
														<option value="2010">2010</option>
														<option value="2011">2011</option>
														<option value="2012">2012</option>
														<option value="2013">2013</option>
														<option value="2014">2014</option>
														<option value="2015">2015</option>
														<option value="2016">2016</option>
														<option value="2017">2017</option>
														<option value="2018">2018</option>
														<option value="2019">2019</option>
														<option value="2020">2020</option>
														<option value="2021">2021</option>
														<option value="2022">2022</option>
														<option value="2023">2023</option>
														<option value="2024">2024</option>
														<option value="2025">2025</option>
														<option value="2026">2026</option>
														<option value="2027">2027</option>
														<option value="2028">2028</option>
														<option value="2029">2029</option>
														<option value="2030">2030</option>
														<option value="2031">2031</option>
														<option value="2032">2032</option>
														<option value="2033">2033</option>
														<option value="2034">2034</option>
														<option value="2035">2035</option>
														<option value="2036">2036</option>
														<option value="2037">2037</option>
														<option value="2038">2038</option>
														<option value="2039">2039</option>
														<option value="2040">2040</option>
														<option value="2041">2041</option>
														<option value="2042">2042</option>
														<option value="2043">2043</option>
														<option value="2044">2044</option>
														<option value="2045">2045</option>
														<option value="2046">2046</option>
														<option value="2047">2047</option>
														<option value="2048">2048</option>
														<option value="2049">2049</option>
														<option value="2050">2050</option>
														<option value="2051">2051</option>
														<option value="2052">2052</option>
														<option value="2053">2053</option>
														<option value="2054">2054</option>
														<option value="2055">2055</option>
														<option value="2056">2056</option>
														<option value="2057">2057</option>
														<option value="2058">2058</option>
														<option value="2059">2059</option>
														<option value="2060">2060</option>
														<option value="2061">2061</option>
														<option value="2062">2062</option>
														<option value="2063">2063</option>
														<option value="2064">2064</option>
														<option value="2065">2065</option>
														<option value="2066">2066</option>
														<option value="2067">2067</option>
														<option value="2068">2068</option>
														<option value="2069">2069</option>
														<option value="2070">2070</option>
														<option value="2071">2071</option>
														<option value="2072">2072</option>
														<option value="2073">2073</option>
														<option value="2074">2074</option>
														<option value="2075">2075</option>
														<option value="2076">2076</option>
														<option value="2077">2077</option>
														<option value="2078">2078</option>
														<option value="2079">2079</option>
														<option value="2080">2080</option>
														<option value="2081">2081</option>
														<option value="2082">2082</option>
														<option value="2083">2083</option>
														<option value="2084">2084</option>
														<option value="2085">2085</option>
														<option value="2086">2086</option>
														<option value="2087">2087</option>
														<option value="2088">2088</option>
														<option value="2089">2089</option>
														<option value="2090">2090</option>
														<option value="2091">2091</option>
														<option value="2092">2092</option>
														<option value="2093">2093</option>
														<option value="2094">2094</option>
														<option value="2095">2095</option>
														<option value="2096">2096</option>
														<option value="2097">2097</option>
														<option value="2098">2098</option>
														<option value="2099">2099</option>
													</select>
													<label for="q1131822_q2_value_h">Hour</label>
													<select name="q1131822_q2_value[h]" id="q1131822_q2_value_h" class="sq-form-field">
														<option value="--"></option>
														<option value="0">00</option>
														<option value="1">01</option>
														<option value="2">02</option>
														<option value="3">03</option>
														<option value="4">04</option>
														<option value="5">05</option>
														<option value="6">06</option>
														<option value="7">07</option>
														<option value="8">08</option>
														<option value="9">09</option>
														<option value="10">10</option>
														<option value="11">11</option>
														<option value="12">12</option>
														<option value="13">13</option>
														<option value="14">14</option>
														<option value="15">15</option>
														<option value="16">16</option>
														<option value="17">17</option>
														<option value="18">18</option>
														<option value="19">19</option>
														<option value="20">20</option>
														<option value="21">21</option>
														<option value="22">22</option>
														<option value="23">23</option>
													</select>
													<label for="q1131822_q2_value_i">Minute</label>
													<select name="q1131822_q2_value[i]" id="q1131822_q2_value_i" class="sq-form-field">
														<option value="--"></option>
														<option value="0">00</option>
														<option value="1">01</option>
														<option value="2">02</option>
														<option value="3">03</option>
														<option value="4">04</option>
														<option value="5">05</option>
														<option value="6">06</option>
														<option value="7">07</option>
														<option value="8">08</option>
														<option value="9">09</option>
														<option value="10">10</option>
														<option value="11">11</option>
														<option value="12">12</option>
														<option value="13">13</option>
														<option value="14">14</option>
														<option value="15">15</option>
														<option value="16">16</option>
														<option value="17">17</option>
														<option value="18">18</option>
														<option value="19">19</option>
														<option value="20">20</option>
														<option value="21">21</option>
														<option value="22">22</option>
														<option value="23">23</option>
														<option value="24">24</option>
														<option value="25">25</option>
														<option value="26">26</option>
														<option value="27">27</option>
														<option value="28">28</option>
														<option value="29">29</option>
														<option value="30">30</option>
														<option value="31">31</option>
														<option value="32">32</option>
														<option value="33">33</option>
														<option value="34">34</option>
														<option value="35">35</option>
														<option value="36">36</option>
														<option value="37">37</option>
														<option value="38">38</option>
														<option value="39">39</option>
														<option value="40">40</option>
														<option value="41">41</option>
														<option value="42">42</option>
														<option value="43">43</option>
														<option value="44">44</option>
														<option value="45">45</option>
														<option value="46">46</option>
														<option value="47">47</option>
														<option value="48">48</option>
														<option value="49">49</option>
														<option value="50">50</option>
														<option value="51">51</option>
														<option value="52">52</option>
														<option value="53">53</option>
														<option value="54">54</option>
														<option value="55">55</option>
														<option value="56">56</option>
														<option value="57">57</option>
														<option value="58">58</option>
														<option value="59">59</option>
													</select>
													<label for="q1131822_q2_value_s">Second</label>
													<select name="q1131822_q2_value[s]" id="q1131822_q2_value_s" class="sq-form-field">
														<option value="--"></option>
														<option value="0">00</option>
														<option value="1">01</option>
														<option value="2">02</option>
														<option value="3">03</option>
														<option value="4">04</option>
														<option value="5">05</option>
														<option value="6">06</option>
														<option value="7">07</option>
														<option value="8">08</option>
														<option value="9">09</option>
														<option value="10">10</option>
														<option value="11">11</option>
														<option value="12">12</option>
														<option value="13">13</option>
														<option value="14">14</option>
														<option value="15">15</option>
														<option value="16">16</option>
														<option value="17">17</option>
														<option value="18">18</option>
														<option value="19">19</option>
														<option value="20">20</option>
														<option value="21">21</option>
														<option value="22">22</option>
														<option value="23">23</option>
														<option value="24">24</option>
														<option value="25">25</option>
														<option value="26">26</option>
														<option value="27">27</option>
														<option value="28">28</option>
														<option value="29">29</option>
														<option value="30">30</option>
														<option value="31">31</option>
														<option value="32">32</option>
														<option value="33">33</option>
														<option value="34">34</option>
														<option value="35">35</option>
														<option value="36">36</option>
														<option value="37">37</option>
														<option value="38">38</option>
														<option value="39">39</option>
														<option value="40">40</option>
														<option value="41">41</option>
														<option value="42">42</option>
														<option value="43">43</option>
														<option value="44">44</option>
														<option value="45">45</option>
														<option value="46">46</option>
														<option value="47">47</option>
														<option value="48">48</option>
														<option value="49">49</option>
														<option value="50">50</option>
														<option value="51">51</option>
														<option value="52">52</option>
														<option value="53">53</option>
														<option value="54">54</option>
														<option value="55">55</option>
														<option value="56">56</option>
														<option value="57">57</option>
														<option value="58">58</option>
														<option value="59">59</option>
													</select>
												</div>
												<p id="error_1131822_q2" class="sq-form-error">Invalid date/time</p>
											</fieldset>
										</div>
										<div class="sq-form-question sq-form-question-file-upload ">
											<label class="sq-form-question-title" for="q1131822_q4">File upload</label>
											<div class="sq-form-question-answer">
												<div class="sq-form-upload">
													<input type="file" name="q1131822:q4" id="q1131822_q4" class="sq-form-field">
													</div>
												</div>
											</div>
											<div class="sq-form-question sq-form-question-option-list ">
												<fieldset>
													<legend class="sq-form-question-title">Option list</legend>
													<div class="sq-form-question-answer">
														<ul>
															<li>
																<input type="radio" name="q1131822:q6" id="q1131822_q6_0" value="0" class="sq-form-field">
																	<label for="q1131822_q6_0">Option 1</label>
																</li>
																<li>
																	<input type="radio" name="q1131822:q6" id="q1131822_q6_1" value="1" class="sq-form-field">
																		<label for="q1131822_q6_1">Option 2</label>
																	</li>
																	<li>
																		<input type="radio" name="q1131822:q6" id="q1131822_q6_2" value="2" class="sq-form-field">
																			<label for="q1131822_q6_2">Option 3</label>
																		</li>
																	</ul>
																</div>
															</fieldset>
														</div>
														<div class="sq-form-question sq-form-question-tickbox-list ">
															<fieldset>
																<legend class="sq-form-question-title">Checkbox</legend>
																<div class="sq-form-question-answer">
																	<ul>
																		<li>
																			<input type="checkbox" name="q1131822:q10[]" id="q1131822_q10_0" value="0" class="sq-form-field">
																				<label for="q1131822_q10_0">One</label>
																			</li>
																			<li>
																				<input type="checkbox" name="q1131822:q10[]" id="q1131822_q10_1" value="1" class="sq-form-field">
																					<label for="q1131822_q10_1">Two</label>
																				</li>
																				<li>
																					<input type="checkbox" name="q1131822:q10[]" id="q1131822_q10_2" value="2" class="sq-form-field">
																						<label for="q1131822_q10_2">Three</label>
																					</li>
																				</ul>
																			</div>
																		</fieldset>
																	</div>
																	<div class="sq-form-question sq-form-question-tickbox-table ">
																		<fieldset>
																			<legend class="sq-form-question-title">Tickbox table</legend>
																			<em class="sq-form-question-note">Notes</em>
																			<div class="sq-form-question-answer">
																				<div class="ds-table-wrapper">
																					<table class="sq-backend-table" id="q1131822_q11" summary="Summary" cellspacing="0" cellpadding="0" border="0">
																						<caption>Caption</caption>
																						<tbody>
																							<tr>
																								<th class="sq-backend-table-header" scope="col">Header1</th>
																								<th class="sq-backend-table-header" scope="col">Header 2</th>
																								<th class="sq-backend-table-header" scope="col">Header 3</th>
																							</tr>
																							<tr>
																								<th class="sq-backend-table-header" scope="row">Label</th>
																								<td class="sq-backend-table-cell">
																									<input type="checkbox" name="q1131822_q11[0][0]" value="1" id="q1131822_q11_0_0" class="sq-form-field">
																										<label for="q1131822_q11_0_0">value1</label>
																									</td>
																									<td class="sq-backend-table-cell">
																										<input type="checkbox" name="q1131822_q11[0][1]" value="1" id="q1131822_q11_0_1" class="sq-form-field">
																											<label for="q1131822_q11_0_1">value2</label>
																										</td>
																									</tr>
																									<tr class="even">
																										<th class="sq-backend-table-header" scope="row">Label</th>
																										<td class="sq-backend-table-cell">
																											<input type="checkbox" name="q1131822_q11[1][0]" value="1" id="q1131822_q11_1_0" class="sq-form-field">
																												<label for="q1131822_q11_1_0">value3</label>
																											</td>
																											<td class="sq-backend-table-cell">
																												<input type="checkbox" name="q1131822_q11[1][1]" value="1" id="q1131822_q11_1_1" class="sq-form-field">
																													<label for="q1131822_q11_1_1">value4</label>
																												</td>
																											</tr>
																										</tbody>
																									</table>
																								</div>
																							</div>
																						</fieldset>
																					</div>
																				</div>
																				<fieldset class="sq-form-section">
																					<legend class="sq-form-section-title">Section</legend>
																					<div class="sq-form-question sq-form-question-text ">
																						<label class="sq-form-question-title" for="q1131828_q1">Question 1</label>
																						<div class="sq-form-question-answer">
																							<input type="text" name="q1131828:q1" value="" size="30" maxlength="300" id="q1131828_q1" class="sq-form-field">
																							</div>
																						</div>
																					</fieldset>
																					<div class="sq-form-control">
																						<div class="sq-form-captcha">
																							<span id="sq_normal_captcha">
																								<img id="sq_security_key" src="/ds/samples/form-test/_nocache?SQ_ACTION=send_security_key" alt="Security key" border="0">
																									<br>
																										<label for="SQ_SYSTEM_SECURITY_KEY_VALUE">Type the characters you see in the picture above: </label>
																										<br>
																											<input type="text" name="SQ_SYSTEM_SECURITY_KEY_VALUE" value="" size="5" class="sq-form-field" id="SQ_SYSTEM_SECURITY_KEY_VALUE">
																												<br>
																													<span id="SQ_SYSTEM_SECURITY_KEY_VALUE_ERROR" class="sq-form-error sq-captcha-error">Security Key Incorrect</span>
																												</span>
																												<span id="sq_regen_captcha">
																													<br>
																														<i>Can't read the security key? 
																															<a href="#" onclick="var img = document.getElementById('sq_security_key'); img.src = '/ds/samples/form-test/_nocache?SQ_ACTION=send_security_key&amp;regen_key=1&amp;t=' + new Date().getTime(); return false;">Click here to get a new key</a>
																														</i>
																													</span>
																												</div>
																												<input type="submit" name="form_email_1131822_submit" value="Submit" class="sq-form-submit" id="form_email_1131822_submit">
																												</div>
																											</form>