{% extends 'base.html' %} {% load i18n %} {% block page_title %}{% trans 'Request access' %} – {{ block.super }}{% endblock %} {% block content %}

{% trans 'Request an account' %}

{% csrf_token %} {% include 'govuk-frontend/components/error-summary.html' with form=form only %} {% include 'mtp_common/forms/field.html' with field=form.first_name input_classes="govuk-input--width-20" only %} {% include 'mtp_common/forms/field.html' with field=form.last_name input_classes="govuk-input--width-20" only %} {% include 'mtp_common/forms/field.html' with field=form.email input_classes="govuk-input--width-20" only %} {% include 'mtp_common/forms/field.html' with field=form.username input_classes="govuk-input--width-10" only %} {% block sign_up_extras_fields %}{% endblock %} {% include 'mtp_common/forms/textarea.html' with field=form.reason rows=5 only %} {% with field=form.role %} {% endwith %}
{% endblock %}