Assignment 3 • Contact & Confirmation Form

Contact Information

Name

First name Last name

Address Street address Examples: 123 Main St, Apt 4B • 42-B Orchard Rd #12

City State ZIP

Contact

Phone We auto-format as you type. Email

Birth date Date of birth Must be a real date, not in the future.

Message Your message

Confirmation Type COP4813 to confirm you’re human