addons/crm/scripts/php/form.php

   1 <html>
   2 <head>
   3 <title>Contact form</title>
   4 </head>
   5 <body>
   6     <h4>Contact Form</h4>
   7     <form method="post" action="crmlead.php">
   8         <label for="firstname">Firstname</label>
   9             <input type="text" name="name" value="" id="firstname" class="required text" title="Please, fill in your firstname" data-required="true"><br />
  10         <label for="company">Company</label>
  11             <input type="text" name="company" value="" id="company" class="required text" title="Please, fill in your company name" data-required="true"><br />
  12         <label for="jobtitle">Jobtitle</label>
  13             <input type="text" name="jobtitle" value="" id="jobtitle" class="required text" title="Please, fill in your job title" data-required="true"><br />
  14         <label for="email">Email</label>
  15             <input type="text" name="email" value="" id="email" class="required email text" title="Please, enter a valid email address" data-required="true"><br />
  16         <label for="phone">Phone</label>
  17             <input type="text" name="phone" value="" id="phone" class="required phone text" title="Please use international format (eg: +32...)" data-required="true">
  18
  19         <label for="city">City</label>
  20             <input type="text" name="city" value="" id="city" class="required text" title="Please, fill in your city" data-required="true"><br />
  21         <label for="zip">Zipcode</label>
  22             <td><input type="text" name="zip" value="" id="zip" class="required text" title="Please, fill in your zipcode" data-required="true"><br />
  23         <label for="state">State</label><input type="text" name="state" value="" id="state" class="text" title="Please, fill in your state"> <br />
  24         <label> Country : <?php include('countrylist.php'); ?></label> <br />
  25         <label for="employees">No.of employees</label>
  26
  27                 <select class="required" name="employees" title="Please, select the No. of employees" data-required="true">
  28                     <option value=""> -- select an option -- </option>
  29                     <option value="1-5">1-5</option>
  30                     <option value="5-10">5-10</option>
  31                     <option value="10-20">10-20</option>
  32
  33                     <option value="20-100">20-100</option>
  34                     <option value="100-500">100-500</option>
  35                     <option value="500+">500+</option>
  36                 </select><br />
  37
  38               <label for="industry">Industry expertise</label>
  39                 <select class="required select" name="industry" title="Please, select an industry" data-required="true">
  40                     <option value=""> -- select an option -- </option>
  41                     <option value="auction">Auction Houses</option>
  42                     <option value="bank">Bank</option>
  43                     <option value="distribution">Distribution</option>
  44                     <option value="education">Education</option>
  45
  46                     <option value="entertainment">Entertainment</option>
  47                     <option value="erp_integrator">ERP Integrator</option>
  48                     <option value="food_industries">Food industries</option>
  49                     <option value="hotels_restaurants">Hotels &amp; restaurants</option>
  50                     <option value="insurance">Insurance</option>
  51                     <option value="manufacturing">Manufacturing</option>
  52                     <option value="non_profit">Non-Profit</option>
  53                     <option value="public">Public</option>
  54
  55                     <option value="services">Services</option>
  56                     <option value="telecommunication">Telecommunication</option>
  57                     <option value="others">Others</option>
  58                 </select><br />
  59         <p>
  60             <label> About : <textarea name="about"></textarea></textarea></label>
  61         </p>
  62         <p>
  63             <input type="submit" value="Send"/> <input type="reset" />
  64         </p>
  65     </form>
  66
  67 </body>
  68 </html>
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