<div id="you_need_errors" style="max-width: 420px; margin: auto; margin-bottom: 20px; color: red;"></div><form id="you_need_form" class="you-need-form" method="post" action="/wp-login.php?action=register"> <div><input type="hidden" name="requested_service_verification" id="you_need_service_verification"/></div><div><input type="hidden" name="requested_service_calibration" id="you_need_service_calibration"/></div><div><input type="hidden" name="requested_service_repair" id="you_need_service_repair"/></div><div><input type="hidden" name="user_login" id="you_need_username"/></div><div><input type="text" id="you_need_email" placeholder="EMAIL ADDRESS" name="user_email"/> <input type="text" placeholder="CREATE PASSWORD" name="password"/></div><div><input type="text" placeholder="COMPANY NAME" name="company"/></div><div><input type="text" placeholder="First Name" name="first_name"/> <input type="text" placeholder="Last Name" name="last_name"/></div><div><input type="text" placeholder="Phone Number" name="phone_number"/> <input type="text" placeholder="Address" name="address"/></div><div><input type="text" placeholder="State" name="state"/> <input type="text" placeholder="Country" name="country"/></div><div><input style="margin: auto; width: calc(-32px + 100%); margin-bottom: 20px;" type="text" name="requested_service_notes" placeholder="Notes: Please enter your SN# of the unit"/></div><div style="display: flex; flex-direction: column; justify-content: center; align-items: center; margin-bottom: 20px;">[anr-captcha]</div><div><button type="submit" style="font-family: Nunito, sans-serif; font-size: 18px; cursor: pointer; background: lightgray; border: 0; padding: 6px 20px; color: #333; margin-bottom: 20px;">SUBMIT</button></div></form>
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