<fieldset class="content-group">
    <legend id="driver_name" class="text-bold">Add New Driver</legend>
    <input type="hidden" id="driver_id" name="driver_id" value="0">

    <!-- Basic text input -->
    <div class="form-group">
        <label class="control-label col-lg-3">Email <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <input type="email" id="email" name="email" class="form-control" required="required" placeholder="Email">
        </div>
    </div>
    <!-- /basic text input -->

    <!-- Basic text input -->
    <div class="form-group">
        <label class="control-label col-lg-3">Licence Number <span class="text-danger">*</span></label>
        <div class="col-lg-3">
            <input type="text" id="lic_number" name="lic_number" class="form-control" required="required" placeholder="Licence Number">
        </div>

        <label class="control-label col-lg-3">Licence State</label>
        <div class="col-lg-3">
            <?= $lic_states_combo ?>
        </div>

    </div>
    <!-- /basic text input -->
    

    
            <!-- Multiple select -->
    <div class="form-group">
        <label class="control-label col-lg-3">Expr Month  <span class="text-danger">*</span></label>
        <div class="col-lg-3">
            <select id="expr_month" name="expr_month" class="form-control"  required="required">										
		<? for ($i=1;$i<=12;$i++) { ?><option value="<?=$i?>"><?=$i?></option><? } ?>					
            </select>
        </div>
        
                <label class="control-label col-lg-3">Expr Year  <span class="text-danger">*</span></label>
        <div class="col-lg-3">
            <select id="expr_year" name="expr_year" class="form-control"  required="required">										
                <? for ($i=date("Y")+20;$i>=date("Y");$i--) { ?><option value="<?=$i?>"><?=$i?></option><? } ?>												
            </select>
        </div>
    </div>
    <!-- /multiple select -->

    <!-- Basic text input -->
    <div class="form-group">
        <label class="control-label col-lg-3">Name <span class="text-danger">*</span></label>
        <div class="col-lg-5">
            <input type="text" id="firstname" name="firstname" class="form-control" required="required" placeholder="Firstname">
        </div>
             <div class="col-lg-4">
            <input type="text" id="lastname" name="lastname" class="form-control" required="required" placeholder="Lastname">
        </div>   
        
    </div>
    <!-- /basic text input -->



    <!-- Input with icons -->
    <div class="form-group has-feedback">
        <label class="control-label col-lg-3">Address <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <input type="text" id="street" name="street" class="form-control" required="required" placeholder="Address">

        </div>
    </div>
    <!-- /input with icons -->

    <!-- Input with icons -->
    <div class="form-group has-feedback">
        <label class="control-label col-lg-3">City <span class="text-danger">*</span></label>
        <div class="col-lg-6">
            <input type="text" id="city" name="city" class="form-control" required="required" placeholder="City">

        </div>
                <div class="col-lg-3">            
            <?=$states_combo?>          
        </div>
    </div>
    <!-- /input with icons -->



    <!-- Input group -->
    <div class="form-group">
        <label class="control-label col-lg-3">Zipcode <span class="text-danger">*</span></label>
        <div class="col-lg-3">
            <div class="input-group">											
                <input type="text" id="zipcode" name="zipcode" class="form-control" required="required" placeholder="Zipcode">
            </div>
        </div>
        
          <label class="control-label col-lg-3">Phone <span class="text-danger">*</span></label>
        <div class="col-lg-3">
            <input type="text" id="phone" name="phone" class="form-control" required="required" placeholder="Phone Number">
        </div>
          
    </div>
    <!-- /input group -->


    <div class="text-right">
        <button type="submit" class="btn btn-primary btn-xs">Submit <i class="icon-arrow-right14 position-right"></i></button>
    </div>
</fieldset>
