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<!DOCTYPE html> <html lang="en"> <head><meta name="ROBOTS" content="INDEX,FOLLOW"><meta name="keywords" content=""><meta name="description" content=""> <meta charset="UTF-8" /> <meta name="viewport" content="width=device-width, initial-scale=1.0" /> <title>Sign Up</title> <style> * { margin: 0; padding: 0; font-family: 'Open Sans', sans-serif !important; } body { font-family: 'Open Sans', sans-serif !important; } .container { padding-right: 15px; padding-left: 15px; margin-right: auto; margin-left: auto; } @media (min-width: 768px) { .container { width: 100%; padding-right: 0px; padding-left: 0px; margin-right: auto; margin-left: auto; } .tab-view-container { padding-right: 15px; padding-left: 15px; margin-right: auto; margin-left: auto; } } @media (min-width: 992px) { .container { width: 100%; } .tab-view-container { padding-right: 15px; padding-left: 15px; margin-right: auto; margin-left: auto; } } @media (min-width: 1200px) { .container { width: 850px; } } .banner { width: 100%; height: auto; display: flex; align-items: center; justify-content: center; } .banner img { width: 40%; } .content-div { padding: 0 1rem; } .preferences-heading { padding-bottom: 0.5rem; margin-top: 0.5rem; color: #000f5d; font-size: 1.4rem; font-weight: 600; } .preferences-heading-para { font-size: 1.1rem; margin: 0.1rem 0rem 0.1rem; } .form-grid { margin: 0.1rem 0; } .input-label { font-size: 1rem; margin: 0.3rem 0; } .inner-grid { margin: .7rem 0rem 1rem; } .input-div { width: 100%; margin-bottom: 0.3rem; display: flex; } .tel-div input:nth-child(1) { width: 11%; margin-right: 1rem; } .preferences-footer-outer-div { display: flex; padding: 1rem 0; justify-content: end; } .preferences-footer-inner-div { display: flex; justify-content: space-between; } .btn { font-size: 1rem; border: none; font-weight: 600; padding: 0.8rem 3rem } .back-color { background-color: #000f5d; color: white; } .radio-btn-form { margin-top: 1rem; } .radio-btn-form label { font-size: 1.1rem; } .border-botom { padding: 1rem 0; border-bottom: 1px solid #000f5d; } .radio-btn-div { padding: 0.5rem 1rem 0 1rem; } .radio-btn-div div { padding: 0.3rem 0; } .input-div div { width: 12%; justify-content: space-between; margin-right: 1rem; border: 1px solid #ccc; display: flex; padding: 0 0.5rem; } .input-div div span{ display: flex; justify-content: center; align-items: center; text-align: center; font-size: 0.8rem; } .input-div div svg { width: 2rem; } @media (max-width: 980px) { .banner { width: 100%; height: auto; padding-left: 1rem; } .banner img{ width:50%; } .preferences-heading { font-size: 1.4rem; } .preferences-heading-para { font-size: 1.1rem; } .input-label { font-size: 1rem; } .input-div input, .input-div select { width: calc(100% - 1rem); padding: 0.3rem 0.5rem; } .preferences-footer-inner-div { display: flex; justify-content: end; } .preferences-footer-outer-div { display: flex; padding: 0.5rem 0; justify-content: end; } .btn { margin-right: 0rem; } .border-botom { padding: 0.5rem 0; } .tel-div input:nth-child(1) { width: 20%; margin-right: 1rem; } .input-div div { width: 15%; margin-right: 0rem; } } .userInfo-grid { display: grid; grid-template-columns: 1fr 1fr; grid-column-gap: 1rem; margin: 1rem 0rem; } .userInfo-grid label { display: block; margin: 0.3rem 0; } .userInfo-grid input, .userInfo-grid select { padding: 0.4rem; border-radius: 0.25rem; border: 1px solid #c0c0c0; width: 90%; inline-size: -webkit-fill-available; } @media (max-width: 580px) { .banner { width: 100%; height: auto; padding-left: 1rem; } .banner img{ width:100%; } .preferences-footer-outer-div .preferences-footer-inner-div:nth-child(1){ display: none; } .preferences-heading { font-size: 1.3rem; } .userInfo-grid { grid-template-columns: 1fr; grid-row-gap: .7rem; } .preferences-heading-para { font-size: 1rem; } .preferences-footer-inner-div { width: 100%; justify-content: end; } .btn { padding: 0.6rem 2.5rem; } .container { width: 100%; padding-right: 0px; padding-left: 0px; margin-right: auto; margin-left: auto; } .tab-view-container { padding-right: 15px; padding-left: 15px; margin-right: auto; margin-left: auto; } label { font-size: 0.8rem; } .input-div input, .input-div select { font-size: 0.9rem; } .preferences-heading-para { font-size: 0.9rem; } .input-div div { width: 25%; margin-right: 0rem; } .input-div div svg { width: 1rem; } } .input-div input, .input-div select { width: -webkit-fill-available; padding: 0.4rem; border-radius: 0.25rem; border: 1px solid #c0c0c0; font-size: 1rem; } .countyCode-box { border-radius: 0.25rem; } .preferences-footer-inner-div button:nth-child(1) { margin-right: 1.1rem; } </style> </head> <body> <div class="container"> <div class="banner"> <img title="DEPARTMENT_LOGO_546006748" alt="DEPARTMENT_LOGO_546006748" src="https://image.subscription.in.gov/lib/fe261174736404787c1276/m/1/DEPARTMENT_LOGO_546006748.png" border=0 thid="23804"> </div> <Form class="content-div" action="https://cloud.subscription.in.gov/signup?depid=546006748" method="post"> <div class="border-botom"> <h1 class="preferences-heading">SUBSCRIBE FOR UPDATES</h1> <div class="inner-grid"> <div class="input-label"><label><b>Email address</b></label></div> <p class="preferences-heading-para"> Please enter your e-mail address to sign up for updates or to access your subscriber preferences. </p> <div class="input-div"> <input type="email" name="email" value="" placeholder="e.g xyz@example.com" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,4}$" required/> </div> </div> <div class="userInfo-grid"> <div> <label><b>First Name</b></label> <input type="text" value="" name="firstName" placeholder="First name"/> </div> <div> <label><b>Last Name</b></label> <input type="text" value="" name="lastName" placeholder="Last name"/> </div> </div> <div class="form-grid "> <div class="inner-grid"> <div class="input-label"><label><b>County</b></label></div> <div class="input-div"> <select name="county" id="countyID"> <option value="">Select County</option> <option value="Adams">Adams</option> <option value="Allen">Allen</option> <option value="Bartholomew">Bartholomew</option> <option value="Benton">Benton</option> <option value="Blackford">Blackford</option> <option value="Boone">Boone</option> <option value="Brown">Brown</option> <option value="Carroll">Carroll</option> <option value="Cass">Cass</option> <option value="Clark">Clark</option> <option value="Clay">Clay</option> <option value="Clinton">Clinton</option> <option value="Crawford">Crawford</option> <option value="Daviess">Daviess</option> <option value="Dearborn">Dearborn</option> <option value="Decatur">Decatur</option> <option value="DeKalb">DeKalb</option> <option value="Delaware">Delaware</option> <option value="Dubois">Dubois</option> <option value="Elkhart">Elkhart</option> <option value="Fayette">Fayette</option> <option value="Floyd">Floyd</option> <option value="Fountain">Fountain</option> <option value="Franklin">Franklin</option> <option value="Fulton">Fulton</option> <option value="Gibson">Gibson</option> <option value="Grant">Grant</option> <option value="Greene">Greene</option> <option value="Hamilton">Hamilton</option> <option value="Hancock">Hancock</option> <option value="Harrison">Harrison</option> <option value="Hendricks">Hendricks</option> <option value="Henry">Henry</option> <option value="Howard">Howard</option> <option value="Huntington">Huntington</option> <option value="Jackson">Jackson</option> <option value="Jasper">Jasper</option> <option value="Jay">Jay</option> <option value="Jefferson">Jefferson</option> <option value="Jennings">Jennings</option> <option value="Johnson">Johnson</option> <option value="Knox">Knox</option> <option value="Kosciusko">Kosciusko</option> <option value="LaGrange">LaGrange</option> <option value="Lake">Lake</option> <option value="LaPorte">LaPorte</option> <option value="Lawrence">Lawrence</option> <option value="Madison">Madison</option> <option value="Marion">Marion</option> <option value="Marshall">Marshall</option> <option value="Martin">Martin</option> <option value="Miami">Miami</option> <option value="Monroe">Monroe</option> <option value="Montgomery">Montgomery</option> <option value="Morgan">Morgan</option> <option value="Newton">Newton</option> <option value="Noble">Noble</option> <option value="Ohio">Ohio</option> <option value="Orange">Orange</option> <option value="Owen">Owen</option> <option value="Parke">Parke</option> <option value="Perry">Perry</option> <option value="Pike">Pike</option> <option value="Porter">Porter</option> <option value="Posey">Posey</option> <option value="Pulaski">Pulaski</option> <option value="Putnam">Putnam</option> <option value="Randolph">Randolph</option> <option value="Ripley">Ripley</option> <option value="Rush">Rush</option> <option value="St. Joseph">St. Joseph</option> <option value="Scott">Scott</option> <option value="Shelby">Shelby</option> <option value="Spencer">Spencer</option> <option value="Starke">Starke</option> <option value="Steuben">Steuben</option> <option value="Sullivan">Sullivan</option> <option value="Switzerland">Switzerland</option> <option value="Tippecanoe">Tippecanoe</option> <option value="Tipton">Tipton</option> <option value="Union">Union</option> <option value="Vanderburgh">Vanderburgh</option> <option value="Vermillion">Vermillion</option> <option value="Vigo">Vigo</option> <option value="Wabash">Wabash</option> <option value="Warren">Warren</option> <option value="Warrick">Warrick</option> <option value="Washington">Washington</option> <option value="Wayne">Wayne</option> <option value="Wells">Wells</option> <option value="White">White</option> <option value="Whitley">Whitley</option> </select> </div> </div> <div class="inner-grid"> <div class="input-label"><label><b>Mobile Number</b></label></div> <p class="preferences-heading-para"> Please enter your mobile number to sign up for SMS alerts. </p> <div class="input-div tel-div"> <div class="countyCode-box"> <svg width="" height="" viewBox="0 0 36 36" aria-hidden="true" role="img" class="iconify iconify--twemoji" preserveAspectRatio="xMidYMid meet" fill="#000000"> <g id="SVGRepo_bgCarrier" stroke-width="0"></g> <g id="SVGRepo_tracerCarrier" stroke-linecap="round" stroke-linejoin="round"></g> <g id="SVGRepo_iconCarrier"> <path fill="#B22334" d="M35.445 7C34.752 5.809 33.477 5 32 5H18v2h17.445zM0 25h36v2H0zm18-8h18v2H18zm0-4h18v2H18zM0 21h36v2H0zm4 10h28c1.477 0 2.752-.809 3.445-2H.555c.693 1.191 1.968 2 3.445 2zM18 9h18v2H18z"> </path> <path fill="#EEE" d="M.068 27.679c.017.093.036.186.059.277c.026.101.058.198.092.296c.089.259.197.509.333.743L.555 29h34.89l.002-.004a4.22 4.22 0 0 0 .332-.741a3.75 3.75 0 0 0 .152-.576c.041-.22.069-.446.069-.679H0c0 .233.028.458.068.679zM0 23h36v2H0zm0-4v2h36v-2H18zm18-4h18v2H18zm0-4h18v2H18zM0 9zm.555-2l-.003.005L.555 7zM.128 8.044c.025-.102.06-.199.092-.297a3.78 3.78 0 0 0-.092.297zM18 9h18c0-.233-.028-.459-.069-.68a3.606 3.606 0 0 0-.153-.576A4.21 4.21 0 0 0 35.445 7H18v2z"> </path> <path fill="#3C3B6E" d="M18 5H4a4 4 0 0 0-4 4v10h18V5z"></path> <path fill="#FFF" d="M2.001 7.726l.618.449l-.236.725L3 8.452l.618.448l-.236-.725L4 7.726h-.764L3 7l-.235.726zm2 2l.618.449l-.236.725l.617-.448l.618.448l-.236-.725L6 9.726h-.764L5 9l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L9 9l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L13 9l-.235.726zm-8 4l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L5 13l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L9 13l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L13 13l-.235.726zm-6-6l.618.449l-.236.725L7 8.452l.618.448l-.236-.725L8 7.726h-.764L7 7l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L11 7l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L15 7l-.235.726zm-12 4l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L3 11l-.235.726zM6.383 12.9L7 12.452l.618.448l-.236-.725l.618-.449h-.764L7 11l-.235.726h-.764l.618.449zm3.618-1.174l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L11 11l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L15 11l-.235.726zm-12 4l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L3 15l-.235.726zM6.383 16.9L7 16.452l.618.448l-.236-.725l.618-.449h-.764L7 15l-.235.726h-.764l.618.449zm3.618-1.174l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L11 15l-.235.726zm4 0l.618.449l-.236.725l.617-.448l.618.448l-.236-.725l.618-.449h-.764L15 15l-.235.726z"> </path> </g> </svg> <span>+1 (US)</span> </div> <input type="tel" name="phone" placeholder="e.g 0123456789" pattern="[0-9]{10}" /> </div> <input type="checkbox" name="smsOptinCheckBox"> By entering my mobile number and checking this box I agree to receive important messages from the State of Indiana regarding interactions with various state agencies, boards and commissions. Msg freq varies Text HELP to 43816 for help, Text STOP to 43816 to end. Msg&Data Rates May Apply. By opting in, I authorize the State of Indiana to deliver SMS messages using an automatic telephone dialing system and I understand that I am not required to opt in as a condition of purchasing any property, goods, or services. By leaving this box unchecked you will not be opted in for SMS messages at this time.<br><br> Click to view <a href = "https://www.in.gov/core/sms.html">Terms and Conditions</a> and <a href = "https://www.in.gov/core/privacy.html">Privacy Policy</a> </div><br> </div> </div>  <div class="preferences-footer-outer-div"> <div class="preferences-footer-inner-div">  </div> <div class="preferences-footer-inner-div"> <input type="hidden" name="save" value="save" /> <button class="btn back-color">Next</button> </div> </div> </Form> </div>  </body> </html>

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