forked from verdnatura/hedera-web
101 lines
1.6 KiB
PHP
Executable File
101 lines
1.6 KiB
PHP
Executable File
<div id="contact">
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<h1>
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<?=s('IWantCustomer')?>
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</h1>
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<p>
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<?=s('FillFormData')?>
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</p>
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<p>
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<?=s('OrCallUs')?>
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</p>
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<form action="modules/contact/send-data.php" method="post" id="contact-form">
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<table class="form">
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<tbody>
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<tr>
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<td class="label">
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<label><?=s('Name:')?></label>
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</td>
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<td>
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<input type="text" name="name"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('Surname:')?></label>
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</td>
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<td>
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<input type="text" name="surname"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('EMail:')?></label>
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</td>
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<td>
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<input type="text" name="email"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('Message:')?></label>
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</td>
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<td>
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<textarea name="message"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('Address:')?></label>
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</td>
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<td>
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<input type="text" name="address"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('PC:')?></label>
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</td>
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<td>
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<input type="text" name="pc"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('City:')?></label>
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</td>
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<td>
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<input type="text" name="city"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('Phone:')?></label>
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</td>
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<td>
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<input type="text" name="phone"/>
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</td>
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</tr>
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<tr>
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<td class="label">
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<label><?=s('Anti-Spam:')?></label>
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</td>
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<td>
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<img alt="captcha" id="captcha"/>
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<input type="text" name="captcha"/>
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</td>
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</tr>
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</tbody>
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<tfoot>
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<tr>
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<td colspan="2">
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<p>
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<?=s('AllFieldsMandatory')?>
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</p>
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<button><?=s('Send')?></button>
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</td>
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</tr>
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</tfoot>
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</table>
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</form>
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</div>
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