diff --git a/public/assets/css/style.css b/public/assets/css/style.css
index ef00d1b7..96f1f655 100644
--- a/public/assets/css/style.css
+++ b/public/assets/css/style.css
@@ -196,6 +196,81 @@ span.has-danger,
 	top: -0.45rem;
 }
 
+.input-group .form-control:first-child:not(:last-child):not(:focus):not(.focus) {
+    border-right: 0;
+}
+
+.input-group .input-group-append + .form-control:not(:focus):not(.focus) {
+    border-left: 0;
+}
+
+.input-group > .form-control:not(:first-child) {
+	border-top-left-radius: 0;
+    border-bottom-left-radius: 0;
+}
+
+.input-group > .form-control:not(:last-child) {
+	border-top-right-radius: 0;
+    border-bottom-right-radius: 0;
+}
+
+.input-group .input-group-append > .input-group-text {
+	border-color: #ebedf2;
+    background-color: #f4f5f8;
+    color: #575962;
+}
+
+.input-group > .input-group-append > .input-group-text {
+	border-top-left-radius: 0;
+    border-bottom-left-radius: 0;
+}
+
+.input-group > .input-group-append:not(:last-child) > .input-group-text {
+	border-top-right-radius: 0;
+    border-bottom-right-radius: 0;
+}
+
+.input-group-text {
+    display: -webkit-box;
+    display: -ms-flexbox;
+    display: flex;
+    -webkit-box-align: center;
+    -ms-flex-align: center;
+    align-items: center;
+    padding: .85rem 1.15rem;
+    margin-bottom: 0;
+    font-size: 1rem;
+    font-weight: 400;
+    line-height: 1.25;
+    color: #495057;
+    text-align: center;
+    white-space: nowrap;
+    background-color: #e9ecef;
+    border: 1px solid #ced4da;
+    border-radius: .25rem;
+}
+
+.input-daterange input:last-child {
+    border-radius: 0 3px 3px 0;
+}
+
+.input-group {
+    position: relative;
+    display: -webkit-box;
+    display: -ms-flexbox;
+    display: flex;
+    -ms-flex-wrap: wrap;
+    flex-wrap: wrap;
+    -webkit-box-align: stretch;
+    -ms-flex-align: stretch;
+    align-items: stretch;
+    width: 100%;
+}
+
+.input-daterange {
+    width: 100%;
+}
+
 @media (min-width: 995px) {
 	.modal-lg {
 		max-width: 1024px;
diff --git a/templates/report/rejection/form.html.twig b/templates/report/rejection/form.html.twig
new file mode 100644
index 00000000..a6ffb3ef
--- /dev/null
+++ b/templates/report/rejection/form.html.twig
@@ -0,0 +1,82 @@
+{% extends 'base.html.twig' %}
+
+{% block body %}
+	<!-- BEGIN: Subheader -->
+    <div class="m-subheader">
+        <div class="d-flex align-items-center">
+            <div class="mr-auto">
+                <h3 class="m-subheader__title">Rejection Report</h3>
+            </div>
+        </div>
+    </div>
+    <!-- END: Subheader -->
+    <div class="m-content">
+        <!--Begin::Section-->
+        <div class="row">
+            <div class="col-xl-6">
+            	<div class="m-portlet m-portlet--mobile">
+            		<div class="m-portlet__head">
+						<div class="m-portlet__head-caption">
+							<div class="m-portlet__head-title">
+								<span class="m-portlet__head-icon">
+									<i class="fa fa-calendar"></i>
+								</span>
+								<h3 class="m-portlet__head-text">
+									Select a date range
+								</h3>
+							</div>
+						</div>
+					</div>
+                    <form id="row-form" class="m-form m-form--fit m-form--label-align-right m-form--group-seperator-dashed" method="post" action="{{ url('rep_reject_submit') }}">
+						<div class="m-portlet__body">	
+							<div class="form-group m-form__group row">
+								<div class="input-daterange input-group" id="date-range">
+									<input type="text" class="form-control m-input" name="date_start" placeholder="Start date" />
+									<div class="input-group-append">
+										<span class="input-group-text"><i class="la la-ellipsis-h"></i></span>
+									</div>
+									<input type="text" class="form-control" name="date_end" placeholder="End date" />
+								</div>
+							</div>	
+			            </div>
+			            <div class="m-portlet__foot m-portlet__foot--fit">
+							<div class="m-form__actions m-form__actions--solid m-form__actions--right">
+								<div class="row">
+									<div class="col-lg-12">
+										<button type="submit" class="btn btn-success">Submit</button>
+									</div>
+								</div>
+							</div>
+						</div>
+					</form>
+                </div>
+			</div>
+		</div>
+	</div>
+{% endblock %}
+
+{% block scripts %}
+	<script>
+		$(function() {
+			$("#date-range").datepicker({
+				
+			});
+
+			$("#row-form").submit(function(e) {
+				var form = $(this);
+
+				if (!$("[name='date_start']").val() || !$("[name='date_end']").val()) {
+					e.preventDefault();
+
+					swal({
+						title: 'Whoops!',
+						text: 'Please fill in both date fields.',
+						type: 'warning'
+					});
+
+					return false;
+				}
+			}); 
+		});
+	</script>
+{% endblock %}