
<div class="myweb_box">


<style type="text/css"><!--
table#user_init {
	margin-top: 1em;
}
table#user_init th {
	text-align: left;
}
table#user_init td, table#user_init th {
	padding: 2px 2px 2px 0;
}
table#user_init select {
	font-size: 1.5em;
}
table#user_init #home_addr {
	width: 25em;
}
--></style>

<script src="https://cdnjs.cloudflare.com/ajax/libs/jqueryui/1.12.1/jquery-ui.min.js"></script>
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/jqueryui/1.12.1/themes/base/jquery-ui.min.css">
<script type="text/javascript">
	jQuery(document).ready(function($){
		$.datepicker.regional.ja = {
			changeMonth: true,
			changeYear: true,
			yearRange: '-100:+0',
			closeText: "閉じる",
			prevText: "<前",
			nextText: "次>",
			currentText: "今日",
			monthNames: ["1月", "2月", "3月", "4月", "5月", "6月", "7月", "8月", "9月", "10月", "11月", "12月"],
			monthNamesShort: ["1月", "2月", "3月", "4月", "5月", "6月", "7月", "8月", "9月", "10月", "11月", "12月"],
			dayNames: ["日曜日", "月曜日", "火曜日", "水曜日", "木曜日", "金曜日", "土曜日"],
			dayNamesShort: ["日", "月", "火", "水", "木", "金", "土"],
			dayNamesMin: ["日", "月", "火", "水", "木", "金", "土"],
			weekHeader: "週",
			dateFormat: "yy-mm-dd",
			firstDay: 0,
			isRTL: !1,
			showMonthAfterYear: !0,
		}, $.datepicker.setDefaults($.datepicker.regional.ja)
		$('#birthday').datepicker({buttonText: "　", showOn: "button"});

	});
</script>

<form method="post" class="memberpass" action="">
<table id="user_init">
<tr>
	<th colspan="3">
		本人確認のため、以下の項目にお答え下さい。<br>
		全て一致した場合、現在のパスワードを画面に表示します。	</th>
</tr>
<tr>
    <th colspan="2">会員番号<br/>介護支援専門員登録番号</th>
    <td>
        <input type="text" name="user_login" id="user_login" value="">
        <span style="color: gray;">数字8桁</span></td>
    </td>
</tr>
<tr>
	<th rowspan="2">氏名</th>
    <th>姓(漢字)</th>
    <td><input type="text" name="last_name" id="last_name" value=""></td>
</tr>
<tr>
    <th>名(漢字)</th>
    <td><input type="text" name="first_name" id="first_name" value=""></td>
</tr>
<tr>
	<th colspan="2">生年月日</th>
	<td>
		<input type="text" name="birthday" id="birthday" value="" maxlength="10">
        <span style="color: gray;">YYYY-MM-DD形式</span></td>
	</td>
</tr>
<tr>
	<th colspan="2">自宅電話番号または<br/>携帯電話番号</th>
	<td style="vertical-align: middle;">
		<input type="text" name="home_tel" id="home_tel" value="" maxlength="13">
        <span style="color: gray; display: block; float: right;">0999-99-9999/099-999-9999<br/>09-9999-9999/090-9999-9999</span>
	</td>
</tr>


<tr>
	<td colspan="3" align="right">
		<input type="submit" id="user_init_btn" name="user_init_btn" value="送信">
	</td>
</tr>
</table>
</form>


</div>

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