<div class="requestLogin"> <h1><i class="icon-user"></i>Request a login</h1> <form action="login.php" method="POST"> <div class="row"> <div class="input"> <input type="text" class="text" name="firstname" id="firstname" placeholder="First Name" value="" /> <span>*</span> </div> <div class="input last"> <input type="text" class="text" name="lastname" id="lastname" placeholder="Last Name" value="" /> <span>*</span> </div> </div><!-- end of row --> <div class="row"> <div class="input"> <input type="text" class="text" name="website" id="website" placeholder="Primary Website URL" value="" /> <span>*</span> </div> <div class="input last"> <input type="text" class="text" name="accountno" id="accountno" placeholder="Account no. (if known)" value="" /> </div> </div><!-- end of row --> <div class="row"> <div class="input"> <input type="email" class="text" name="email" id="email" placeholder="Email Address" value="" /> <span>*</span> </div> <div class="input last"> <input type="password" class="text" name="preferredpassword" id="preferredpassword" placeholder="Preferred Password" /> </div> </div><!-- end of row --> <div class="row"> <div class="input fullWidth left"> <textarea class="text" name="additional" id="additional" placeholder="Any additional information"></textarea> </div> </div><!-- end of row --> <input type="hidden" name="action" value="request" /> <input type="submit" id="submit" class="button" value="Request a login now"/> </form> </div><!-- end of requestLogin -->