<div class="form-group <?php 
echo $this->getErrorMsg('email') ? 'has-error has-feedback' : ($this->getRequest('email') ? 'has-success has-feedback' : '');
?>
">
                <label for="inputEmail">EMAIL ADDRESS</label>
                <input value="<?php 
echo DataValidateExt::clear_html_string($this->getRequest('email'));
?>
" type="email" id="inputEmail" name="email" class="form-control" placeholder="EMAIL ADDRESS" title="<?php 
echo $this->getErrorMsg('email') ? DataValidateExt::clear_html_string($this->getErrorMsg('email')) : 'EMAIL ADDRESS';
?>
" required>
                <span class="glyphicon <?php 
echo $this->getErrorMsg('email') ? 'glyphicon-remove' : ($this->getRequest('email') ? 'glyphicon-ok' : '');
?>
 form-control-feedback" aria-hidden="true"></span>
            </div>
            
            
            <div class="form-group <?php 
echo $this->getErrorMsg('lastname') ? 'has-error has-feedback' : ($this->getRequest('lastname') ? 'has-success has-feedback' : '');
?>
">
                <label for="inputLastname">LASTNAME</label>
                <input value="<?php 
echo DataValidateExt::clear_html_string($this->getRequest('lastname'));
?>
" type="text" id="inputLastname" name="lastname" class="form-control" placeholder="LASTNAME" title="<?php 
echo $this->getErrorMsg('lastname') ? DataValidateExt::clear_html_string($this->getErrorMsg('lastname')) : 'LASTNAME';
?>
" required>
                <span class="glyphicon <?php 
echo $this->getErrorMsg('lastname') ? 'glyphicon-remove' : ($this->getRequest('lastname') ? 'glyphicon-ok' : '');
?>
 form-control-feedback" aria-hidden="true"></span>
            </div>
            <div class="form-group <?php 
echo $this->getErrorMsg('comments') ? 'has-error' : ($this->getRequest('comments') ? 'has-success has-feedback' : '');
?>
">
                <label for="inputComments">COMMENT</label>
                <textarea id="inputComments" name="comments" class="form-control" rows="5" placeholder="COMMENT" title="<?php 
echo $this->getErrorMsg('comments') ? DataValidateExt::clear_html_string($this->getErrorMsg('comments')) : '';
?>
"><?php 
echo DataValidateExt::clear_html_string($this->getRequest('comments'));
?>
</textarea>
                <span class="glyphicon <?php 
echo $this->getErrorMsg('comments') ? 'glyphicon-remove' : ($this->getRequest('comments') ? 'glyphicon-ok' : '');
?>
 form-control-feedback" aria-hidden="true"></span>
            </div>
            
            <div class="form-group <?php 
echo $this->getErrorMsg('dob') ? 'has-error has-feedback' : ($this->getRequest('dob') ? 'has-success has-feedback' : '');
?>
" title="<?php 
echo $this->getErrorMsg('dob') ? DataValidateExt::clear_html_string($this->getErrorMsg('dob')) : 'DATE OF BIRTH';
?>
">
                <label for="inputDay">DATE OF BIRTH</label>
                <div class="block-datefield">
                    <div class="datefield">
                        <input value="<?php 
echo DataValidateExt::clear_html_string($this->getRequest('dob-dd'));
?>
" id="inputDay" name="dob-dd" type="tel" maxlength="2" placeholder="DD" required /> /
                        <input value="<?php 
echo DataValidateExt::clear_html_string($this->getRequest('dob-mm'));
?>
" id="inputMonth" name="dob-mm" type="tel" maxlength="2" placeholder="MM" required /> /
                        <input value="<?php 
echo DataValidateExt::clear_html_string($this->getRequest('dob-yyyy'));
?>
" id="inputYear" name="dob-yyyy" type="tel" maxlength="4" placeholder="YYYY" required />
                        <span class="glyphicon <?php 
echo $this->getErrorMsg('dob') ? 'glyphicon-remove' : ($this->getRequest('dob') ? 'glyphicon-ok' : '');
?>
 form-control-feedback" aria-hidden="true"></span>
                    </div>
                </div>
            </div>
            
<table border="1" style="width:100%" cellspacing="5" cellpadding="5">
<?php 
foreach ($this->aryRequest as $strField => $strData) {
    ?>
<tr>
    <th><?php 
    echo DataValidateExt::clear_html_string($strField);
    ?>
</th>
    <td><?php 
    echo DataValidateExt::clear_html_string($this->getRequest($strField));
    ?>
</td>
</tr>
<?php 
}
?>
</table>