								<label class="col-form-label col-md-3 col-sm-3 label-align" for="last-name">Last Name <span class="required">*</span>
											</label>
											<div class="col-md-6 col-sm-6 ">
												<input type="text" id="last-name" name="last-name" required="required" class="form-control">
											</div>
										</div>
										<div class="item form-group">
											<label for="middle-name" class="col-form-label col-md-3 col-sm-3 label-align">Middle Name / Initial</label>
											<div class="