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class='gfield_label gform-field-label' for='input_38_3' >Last Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_38_3' type='text' value='' class='large' placeholder='Last Name' aria-required="true" aria-invalid="false" /> </div></div><div id="field_38_12" class="gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_38_12"><label class='gfield_label gform-field-label' for='input_38_12' >Do you currently have a LifeSafer device installed?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_38_12' class='large gfield_select' aria-required="true" 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gform-field-label' for='input_38_5' >State<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_38_5' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Choose State</option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option 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