= simple_form_for @region_license, url: company_region_license_path(@region_license), turboboost: true, validate: true, html: {id: 'new-trade', class: 'form-horizontal dirtyform'} do |f|
  .form-group
    label.col-sm-3.control-label for=""  License Name
    .col-sm-5
      = f.object.license.try(:name)
  .form-group
    label.col-sm-3.control-label for=""  License Number
    .col-sm-5
      = f.input :number, as: :string, label: false
  .form-group
    label.col-sm-3.control-label for="" Classifications
    .col-sm-5
      = f.input :classifications, as: :string, label: false
  .form-group
    label.col-sm-3.control-label for="" Expiration Date
    .col-sm-1.right
      = f.input :expires_on, as: :string, label: false, wrapper: :vertical_input_group do
        = f.input_field :expires_on, as: :string, class: "datepicker", value: f.object.expires_on.try(:strftime, '%m-%d-%Y')
  .form-group
    label.col-sm-3.control-label for="" State registered to collect taxes
    .col-sm-5
      = f.input :state, as: :select, collection: State.all.map(&:name), label: false
  = hidden_field_tag :step, :details
  .row
    .col-sm-12
      .pull-right
        button.btn.btn-cancel data-dismiss="modal" type="button" Cancel
        |      
        = f.button :submit, 'SAVE', class: 'btn btn-save'