<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="user_login" id="you_need_username"/></div><div><input type="text" id="you_need_email" placeholder="EMAIL ADDRESS" name="user_email"/></div><div><input type="text" placeholder="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 style="display: flex; flex-direction: row; justify-content: space-between; text-align: left;"> <input type="text" name="requested_service_notes" placeholder="Enter SN#" style="max-height: 20px; margin-left: 7px;"/> <div style="width: 50%; box-sizing: border-box; padding-left: 25px;"> <div> <input type="checkbox" class="woocommerce-Input woocommerce-Input--checkbox input-checkbox" name="requested_service_calibration" id="requested_service_calibration" value="1"/> <label for="requested_service_calibration" style="display: inline; user-select: none;">Calibration</label> </div><div> <input type="checkbox" class="woocommerce-Input woocommerce-Input--checkbox input-checkbox" name="requested_service_verification" id="requested_service_verification" value="1"/> <label for="requested_service_verification" style="display: inline; user-select: none;">Verification</label> </div><div> <input type="checkbox" class="woocommerce-Input woocommerce-Input--checkbox input-checkbox" name="requested_service_repair" id="requested_service_repair" value="1"/> <label for="requested_service_repair" style="display: inline; user-select: none;">Repair</label> </div><div> <input type="checkbox" class="woocommerce-Input woocommerce-Input--checkbox input-checkbox" name="requested_service_inhouse" id="requested_service_inhouse" value="1"/> <label for="requested_service_inhouse" style="display: inline; user-select: none;">Inhouse</label> </div><div> <input type="checkbox" class="woocommerce-Input woocommerce-Input--checkbox input-checkbox" name="requested_service_onsite" id="requested_service_onsite" value="1"/> <label for="requested_service_onsite" style="display: inline; user-select: none;">Repair</label> </div></div></div><div style="display: flex; flex-direction: column; justify-content: center; align-items: center; margin-bottom: 20px; margin-top: 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>