+
+<div id="request-account-form" title="Request an Account" style="display: none;">
+ <form>
+ <fieldset>
+ <div class="request-form-row">
+ <label for="request-first-name">First Name</label>
+ <input type="text" name="request-first-name" id="request-first-name">
+ </div>
+ <div class="request-form-row">
+ <label for="request-last-name">Last Name</label>
+ <input type="text" name="request-last-name" id="request-last-name">
+ </div>
+ <div class="request-form-row">
+ <label for="request-email">Email</label>
+ <input type="text" name="request-email" id="request-email">
+ </div>
+ <div class="request-form-row">
+ <label for="request-site-name">Site</label><br>
+ <select id="request-site-name" name="request-site-name">
+ <option>---------</option>
+ <option>Stanford</option>
+ <option>Washington</option>
+ <option>Princeton</option>
+ <option>GeorgiaTech</option>
+ <option>MaxPlanck</option>
+ <option>I2 Atlanta</option>
+ <option>I2 Chicago</option>
+ <option>I2 Houston</option>
+ <option>I2 Kansas City</option>
+ <option>I2 Los Angeles</option>
+ <option>I2 New York</option>
+ <option>I2 Salt Lake City</option>
+ <option>I2 Seattle</option>
+ <option>I2 Washington DC</option>
+ <option>ON.Lab</option>
+ <option>I2 Singapore</option>
+ <option>Arizona</option>
+ </select>
+ </div>
+ <div class="submit-row">
+ <input id ="request-signup" class="btn btn-info" value="SIGN UP">
+ </div>
+ </fieldset>
+ </form>
+</div>
+</div>
+</div>
+
+