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Current File : /home2/ppcad7no/vermaborewell.co.in/enquiry.php
<?php include("site-header.php");?>
  <!-- Start main-content -->
  <div class="main-content">
    <!-- Section: inner-header -->
 <?php include("site-header-flash-inner.php");?>
<?php include("send-enquiry-code-product.php");?>  
    <!-- Section: Services -->
    <section class="divider parallax layer-overlay overlay-light">
      <div class="container">
 <div class="col-md-12 text-center <?=$clrerr?>" ><?=display_sess_msg()?></div>
         
        <div class="row pt-30">
          <div class="col-md-9">
            <h3 class="mt-0 mb-30 text-white">Enquiry Form</h3>
            <!-- Contact Form -->
            <form id="contact_form" name="contact_form" class="form-transparent" action="" method="post" onSubmit="return EnqValidation();">
              <div class="row">
                <div class="col-sm-6">
                  <div class="form-group">
                    <label for="form_name">Name <small>*</small></label>
                    <input id="enquiry_nam" name="enquiry_nam" class="form-control" type="text" placeholder="Enter Name" >
                  </div>
                </div>
                <div class="col-sm-6">
                  <div class="form-group">
                    <label for="form_email">Email <small>*</small></label>
                    <input id="enquiry_emai" name="enquiry_emai" class="form-control  " type="email" placeholder="Enter Email">
                  </div>
                </div>
              </div>
              <div class="row">
                <div class="col-sm-6">
                  <div class="form-group">
                    <label for="form_name">Subject <small>*</small></label>
                    <input id="enquiry_sub" name="enquiry_sub" class="form-control " type="text" placeholder="Enter Subject">
                  </div>
                </div>
                <div class="col-sm-6">
                  <div class="form-group">
                    <label for="form_phone">Phone</label>
                    <input id="enquiry_mobil" name="enquiry_mobil" class="form-control" type="text" placeholder="Enter Phone">
                  </div>
                </div>
              </div>
              <div class="form-group">
                <label for="form_name">Message</label>
                <textarea id="enquiry_detai" name="enquiry_detai" class="form-control " rows="5" placeholder="Enter Message"></textarea>
              </div>
              
              <div class="row">
                <div class="col-sm-6">
                  <div class="form-group">
                    <label for="form_phone">Security Code</label>
                    <br>
                    <input id="security_cod" name="captcha" class="form-control pull-left" style="width:70%;"  type="text" placeholder="Enter Security Code">
                    <img src="amitabhcaptcha.php" class="pull-left"   width="80" height="44" alt="Captcha" id="cap" /> </div>
                </div>
              </div>
              
              <div class="form-group" style="margin-top:20px;">
                <input id="form_botcheck" name="form_botcheck" class="form-control" type="hidden" value="" />
                <button type="submit" name="EnqSubmit" class="btn btn-dark btn-theme-colored btn-flat mr-5" data-loading-text="Please wait...">Send your enquiry</button>
                <button type="reset" class="btn btn-default btn-flat btn-theme-colored">Reset</button>
              </div>
            </form>
            <!-- Contact Form Validation-->
            
          </div>
          <div class="col-md-3">
            <div class="row">
              <div class="col-xs-12 col-sm-12 col-md-12">
                <img src="images/enquiry.png" class="img-responsive hidden-xs" style="padding-top:100px;">
              </div>
            </div>
          </div>
        </div>
      </div>
    </section>    
    <!-- Section: Practices Area -->
    <!-- Section: Services -->
  </div>
  <!-- end main-content -->
<?php include("site-footer.php");?>

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