<commit_before><h1>Apply for Medi-Cal</h1>
<hr>
<form role="form" name="apply" action="applications" method="post">
  <div class="form-group">
    <label for="name_first">First name</label>
      <input type="text" class="form-control" name="name_first" id="name_first" placeholder="Juanita">
      <span class="help-block">Include your legal first name.</span>
  </div>

  <div class="form-group">
    <label for="name_middle_initial">Middle initial</label>
      <input type="text" class="form-control" name="name_middle_initial" id="name_middle_initial" placeholder="Q">
      <span class="help-block">Include the initial of your legal middle name, if you have one.</span>
  </div>

  <div class="form-group">
    <label for="name_last">Last name</label>
      <input type="text" class="form-control" name="name_last" id="name_last" placeholder="Smith">
      <span class="help-block">Include your legal last name.</span>
  </div>

  <div class="form-group">
    <label for="home_address">Address</label>
      <input type="text" class="form-control" name="home_address" placeholder="1234 Example Street">
    <label for="home_apt">Apartment number</label>
      <input type="text" class="form-control" name="home_apt" placeholder="Apt. 3"> <!-- @todo: Determine whether this needs to be in a separate field on the PDF for it to be usable. -->
    <label for="home_city">City</label> <!-- @todo: Reconcile with home_city_state -->
      <input type="text" class="form-control" name="home_city" placeholder="San Francisco">
      <div class="input-group">
        <input type="text" class="form-control" name="home_zip_code" placeholder="941...">
      </div>
      <span class="help-block">You have to live in California to be eligible for Medi-Cal. If you don't live in California, apply for Medicaid.</span>
  </div>

  <div class="form-group">
    <label for="home_county">County</label>
      <input type="text" class="form-control" name="home_county" id="home_county" placeholder="San Francisco">
      <span class="help-block">The county in which you live.</span>
  </div>

  <div class="form-group">
    <label for="mailing_address">Mailing address (if different from above) or P.O. box</label>
      <input type="text" class="form-control" name="mailing_address" placeholder="1234 Example Street">
    <label for="mailing_apt">Apartment number</label>
      <input type="text" class="form-control" name="mailing_apt" placeholder="Apt. 3"> <!-- @todo: Determine whether this needs to be in a separate field on the PDF for it to be usable. -->
    <label for="mailing_city_state">City</label> <!-- @todo: Reconcile with home_city_state -->
      <input type="text" class="form-control" name="mailing_city_state" placeholder="San Francisco">
      <div class="input-group">
        <input type="text" class="form-control" name="mailing_zip" placeholder="941...">
      </div>
  </div>

  <!-- State: CA -->
  <input type="hidden" class="form-control" name="home_state" value="CA">

  <!-- Phone numbers -->
  <!-- @todo: Make clear which of these fields are NOT required and what their intended use is. -->
  <!-- "Message number" -->
  <div class="form-group">
    <label for="message_phone_number_area_code">Area code</label>
      <input type="text" class="form-control" name="message_phone_number_area_code" placeholder="415">
    <label for="message_phone_number">Phone number</label>
      <input type="text" class="form-control" name="message_phone_number" placeholder="555-5555">
      <span class="help-block">A phone number where it's okay to leave a message.</span>
  </div>

  <!-- Home number -->
  <div class="form-group">
    <label for="home_phone_number_area_code">Area code</label>
      <input type="text" class="form-control" name="home_phone_number_area_code" placeholder="415">
    <label for="home_phone_number">Home phone number</label>
      <input type="text" class="form-control" name="home_phone_number" placeholder="555-5555">
  </div>

  <!-- Work number -->
  <div class="form-group">
    <label for="work_phone_number_area_code">Area code</label>
      <input type="text" class="form-control" name="work_phone_number_area_code" placeholder="415">
    <label for="work_phone_number">Work phone number</label>
      <input type="text" class="form-control" name="work_phone_number" placeholder="555-5555">
      <span class="help-block">A work number where we can reach you, if applicable.</span>
  </div>

  <div class="form-group">
    <label for="email">Email</label>
      <input type="text" class="form-control" name="email" placeholder="<EMAIL>">
      <span class="help-block">You don't have to include your phone number or email address, but it will help us get in touch with you.</span>
  </div>

  <div class="form-group">
    <label for="language_speak">What language/dialect do you speak best?</label>
      <input type="text" class="form-control" name="language_speak" placeholder="Spanish">
      <span class="help-block">You don't have to include this, but it will help us communicate with you.</span>
  </div>
  <div class="form-group">
    <label for="language_read">What language do you read best?</label>
      <input type="text" class="form-control" name="language_read" placeholder="English">
      <span class="help-block">You don't have to include this, but it will help us communicate with you.</span>
  </div>

  <div class="form-group">
    <label for="signature">Signature</label>
      <div id="signature_area" class="panel"></div>
      <div id="signature_value_hidden"></div>
      <span class="help-block">Sign on the line. You can sign with your mouse or your finger if you're using a touch screen.</span>
  </div>

    <div class="form-group">
        <button type="submit" id="submit_button" class="btn btn-default">Submit your Medi-Cal application!</button>
    </div>
</form>
<commit_msg>Remove home and work phone numbers, leaving message number.<commit_after><h1>Apply for Medi-Cal</h1>
<hr>
<form role="form" name="apply" action="applications" method="post">
  <div class="form-group">
    <label for="name_first">First name</label>
      <input type="text" class="form-control" name="name_first" id="name_first" placeholder="Juanita">
      <span class="help-block">Include your legal first name.</span>
  </div>

  <div class="form-group">
    <label for="name_middle_initial">Middle initial</label>
      <input type="text" class="form-control" name="name_middle_initial" id="name_middle_initial" placeholder="Q">
      <span class="help-block">Include the initial of your legal middle name, if you have one.</span>
  </div>

  <div class="form-group">
    <label for="name_last">Last name</label>
      <input type="text" class="form-control" name="name_last" id="name_last" placeholder="Smith">
      <span class="help-block">Include your legal last name.</span>
  </div>

  <div class="form-group">
    <label for="home_address">Address</label>
      <input type="text" class="form-control" name="home_address" placeholder="1234 Example Street">
    <label for="home_apt">Apartment number</label>
      <input type="text" class="form-control" name="home_apt" placeholder="Apt. 3"> <!-- @todo: Determine whether this needs to be in a separate field on the PDF for it to be usable. -->
    <label for="home_city">City</label> <!-- @todo: Reconcile with home_city_state -->
      <input type="text" class="form-control" name="home_city" placeholder="San Francisco">
      <div class="input-group">
        <input type="text" class="form-control" name="home_zip_code" placeholder="941...">
      </div>
      <span class="help-block">You have to live in California to be eligible for Medi-Cal. If you don't live in California, apply for Medicaid.</span>
  </div>

  <div class="form-group">
    <label for="home_county">County</label>
      <input type="text" class="form-control" name="home_county" id="home_county" placeholder="San Francisco">
      <span class="help-block">The county in which you live.</span>
  </div>

  <div class="form-group">
    <label for="mailing_address">Mailing address (if different from above) or P.O. box</label>
      <input type="text" class="form-control" name="mailing_address" placeholder="1234 Example Street">
    <label for="mailing_apt">Apartment number</label>
      <input type="text" class="form-control" name="mailing_apt" placeholder="Apt. 3"> <!-- @todo: Determine whether this needs to be in a separate field on the PDF for it to be usable. -->
    <label for="mailing_city_state">City</label> <!-- @todo: Reconcile with home_city_state -->
      <input type="text" class="form-control" name="mailing_city_state" placeholder="San Francisco">
      <div class="input-group">
        <input type="text" class="form-control" name="mailing_zip" placeholder="941...">
      </div>
  </div>

  <!-- State: CA -->
  <input type="hidden" class="form-control" name="home_state" value="CA">

  <!-- Phone numbers -->
  <!-- "Message number" instead of home/work number -->
  <div class="form-group">
    <label for="message_phone_number_area_code">Area code</label>
      <input type="text" class="form-control" name="message_phone_number_area_code" placeholder="415">
    <label for="message_phone_number">Phone number</label>
      <input type="text" class="form-control" name="message_phone_number" placeholder="555-5555">
      <span class="help-block">A phone number where it's okay to leave a message.</span>
  </div>

  <div class="form-group">
    <label for="email">Email</label>
      <input type="text" class="form-control" name="email" placeholder="<EMAIL>">
      <span class="help-block">You don't have to include your phone number or email address, but it will help us get in touch with you.</span>
  </div>

  <div class="form-group">
    <label for="language_speak">What language/dialect do you speak best?</label>
      <input type="text" class="form-control" name="language_speak" placeholder="Spanish">
      <span class="help-block">You don't have to include this, but it will help us communicate with you.</span>
  </div>
  <div class="form-group">
    <label for="language_read">What language do you read best?</label>
      <input type="text" class="form-control" name="language_read" placeholder="English">
      <span class="help-block">You don't have to include this, but it will help us communicate with you.</span>
  </div>

  <div class="form-group">
    <label for="signature">Signature</label>
      <div id="signature_area" class="panel"></div>
      <div id="signature_value_hidden"></div>
      <span class="help-block">Sign on the line. You can sign with your mouse or your finger if you're using a touch screen.</span>
  </div>

    <div class="form-group">
        <button type="submit" id="submit_button" class="btn btn-default">Submit your Medi-Cal application!</button>
    </div>
</form>

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