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type="text" data-validation-required-message="Please enter" required="" placeholder="State/Province " id="State/Province " name="State/Province " class="form-control"> </div> </div> </div> <div class="col-lg-12 col-xs-12"> <div class="form-group"> <div class="input-group"> <input type="text" data-validation-required-message="Please enter" required="" placeholder="Department/Subject" id="Department/Subject" name="Department/Subject" class="form-control"> </div> </div> </div> <div class="col-lg-12 col-xs-12"> <div class="form-group"> <div class="input-group"> <div class="col-sm-12"> <p style="margin-top: 15px; font-size: 16px;font-weight: 600;color: #464646;">Services Required from UI : </p> <div class="checkbox"><label><input type="checkbox" name="remember1" value=" Review Article Writing/ Editing "> Review Article Writing/ Editing</label> </div> <div class="checkbox"><label><input type="checkbox" name="remember2" value=" Research Article Writing/ Editing"> Research Article Writing/ 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