Register

<div class="ultimate_wrapper">
    <div class="um um-register um-625 uimob500" style="opacity: 1;">

        <div class="um-form" data-mode="register">

            <form method="post" action="">

                <div class="um-row _um_row_1 " style="margin: 0 0 30px 0;">
                    <div class="um-col-1">
                        <div id="um_field_625_badge_number" class="um-field um-field-text  um-field-badge_number um-field-text um-field-type_text" data-key="badge_number">
                            <div class="um-field-label">
                                <label for="badge_number-625">Badge Number</label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input autocomplete="off" class="um-form-field valid not-required " type="text" name="badge_number-625" id="badge_number-625" value="" placeholder="" data-validate="" data-key="badge_number">

                            </div>
                        </div>
                        <div id="um_field_625_user_login" class="um-field um-field-text  um-field-user_login um-field-text um-field-type_text" data-key="user_login">
                            <div class="um-field-label">
                                <label for="user_login-625">Username<span class="um-req" title="Required">*</span>
                                </label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="user_login-625" id="user_login-625" value="" placeholder="" data-validate="unique_username" data-key="user_login">

                            </div>
                        </div>
                        <div id="um_field_625_first_name" class="um-field um-field-text  um-field-first_name um-field-text um-field-type_text" data-key="first_name">
                            <div class="um-field-label">
                                <label for="first_name-625">First Name</label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="first_name-625" id="first_name-625" value="" placeholder="" data-validate="" data-key="first_name">

                            </div>
                        </div>
                        <div id="um_field_625_last_name" class="um-field um-field-text  um-field-last_name um-field-text um-field-type_text" data-key="last_name">
                            <div class="um-field-label">
                                <label for="last_name-625">Last Name</label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="last_name-625" id="last_name-625" value="" placeholder="" data-validate="" data-key="last_name">

                            </div>
                        </div>
                        <div id="um_field_625_user_email" class="um-field um-field-text  um-field-user_email um-field-text um-field-type_text" data-key="user_email">
                            <div class="um-field-label">
                                <label for="user_email-625">E-mail Address</label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input autocomplete="off" class="um-form-field valid " type="text" name="user_email-625" id="user_email-625" value="" placeholder="" data-validate="unique_email" data-key="user_email">

                            </div>
                        </div>
                        <div id="um_field_625_user_password" class="um-field um-field-password  um-field-user_password um-field-password um-field-type_password" data-key="user_password">
                            <div class="um-field-label">
                                <label for="user_password-625">Password<span class="um-req" title="Required">*</span>
                                </label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input class="um-form-field valid " type="password" name="user_password-625" id="user_password-625" value="" placeholder="" data-validate="" data-key="user_password">

                            </div>
                        </div>
                        <div id="um_field_625_confirm_user_password" class="um-field um-field-password  um-field-user_password um-field-password um-field-type_password" data-key="confirm_user_password">
                            <div class="um-field-label">
                                <label for="confirm_user_password-625">Confirm Password<span class="um-req" title="Required">*</span>
                                </label>
                                <div class="um-clear"></div>
                            </div>
                            <div class="um-field-area"><input class="um-form-field valid " type="password" name="confirm_user_password-625" id="confirm_user_password-625" value="" placeholder="Confirm Password" data-validate="" data-key="confirm_user_password">

                            </div>
                        </div>
                    </div>
                </div>
                <input type="hidden" name="form_id" id="form_id_625" value="625">

                <p class="um_request_name">
                    <label for="um_request_625">Only fill in if you are not human</label>
                    <input type="hidden" name="um_request" id="um_request_625" class="input" value="" size="25" autocomplete="off">
                </p>

                <input type="hidden" id="_wpnonce" name="_wpnonce" value="d64205e06a"><input type="hidden" name="_wp_http_referer" value="/register/">
                <div class="um-col-alt">

                    <div class="um-left um-half">
                        <input type="submit" value="Register" class="um-button" id="um-submit-btn">
                    </div>
                    <div class="um-right um-half">
                        <a href="https://mdot.local/login/" class="um-button um-alt">
                            Login
                        </a>
                    </div>

                    <div class="um-clear"></div>

                </div>

            </form>

        </div>

    </div>
</div>