pan>
                                <input class="span2" type="text" value="02-16-2012">
                            </div>
                            <select class="chosen span4" data-placeholder="Choose a Country...">
                            <option value=""></option>
                            <option value="United States">United States</option>
                            <option value="United Kingdom">United Kingdom</option>
                            <option value="Afghanistan">Afghanistan</op