Personal

<%= f.label :number %>

<%= f.text_field :number %>

<%= f.label :firstname %>

<%= f.text_field :firstname %>

<%= f.label :lastname %>

<%= f.text_field :lastname %>

<%= f.label :dob %>

<%= f.date_select :dob, :start_year => Time.now.year - 70, :end_year => Time.now.year - 17, :default => Time.now - 30.years %>

<%= f.label :phone %>

<%= f.text_field :phone %>

Tax Info

<%= f.label :ssn %>

<%= f.text_field :ssn %>

<%= f.label :payrate %>

<%= f.text_field :payrate %>

<%= f.label :tax_status %>

<%= f.text_field :tax_status %>

<%= f.label :dependents %>

<%= f.text_field :dependents %>

<%= f.label :hired %>

<%= f.date_select :hired, :start_year => Time.now.year - 10, :end_year => Time.now.year + 1, :default => Time.now %>

Address

<%= f.label :street %>

<%= f.text_field :street %>

<%= f.label :city %>

<%= f.text_field :city %>

<%= f.label :state %>

<%= f.text_field :state %>

<%= f.label :zip %>

<%= f.text_field :zip %>

Vehicle Info

<%= f.label :dl_number %>

<%= f.text_field :dl_number %>

<%= f.label :dl_state %>

<%= f.text_field :dl_state %>

<%= f.label :dl_expire %>

<%= f.text_field :dl_expire %>

<%= f.label :truck %>

<%= f.text_field :truck %>

<%= f.label :trailer %>

<%= f.text_field :trailer %>

<%= f.submit "Submit" %>