" class="form-control" type="text" disabled> " maxlength="10">

" placeholder="Last Name" class="form-control" type="text" disabled> " maxlength="10">

" maxlength="10">

" class="form-control" type="date">

" placeholder="Address" class="form-control" type="text">

" placeholder="City" class="form-control" type="text">

" placeholder="State" class="form-control" type="text">

" placeholder="Postcode" class="form-control" type="number">

" placeholder="Password" class="form-control" type="password">