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<div class="container"> |
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<form class="well form-horizontal" action=" " method="post" id="contact_form"> |
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<fieldset> |
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<!-- Form Name --> |
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<legend>Contact Us Today!</legend> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">First Name</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="first_name" placeholder="First Name" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label" >Last Name</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span> |
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<input name="last_name" placeholder="Last Name" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">E-Mail</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span> |
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<input name="email" placeholder="E-Mail Address" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Phone #</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span> |
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<input name="phone" placeholder="(845)555-1212" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Address</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span> |
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<input name="address" placeholder="Address" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">City</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span> |
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<input name="city" placeholder="city" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Select Basic --> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">State</label> |
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<div class="col-md-4 selectContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span> |
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<select name="state" class="form-control selectpicker" > |
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<option value=" " >Please select your state</option> |
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<option>Alabama</option> |
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<option>Alaska</option> |
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<option >Arizona</option> |
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<option >Arkansas</option> |
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<option >California</option> |
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<option >Colorado</option> |
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<option >Connecticut</option> |
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<option >Delaware</option> |
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<option >District of Columbia</option> |
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<option> Florida</option> |
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<option >Georgia</option> |
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<option >Hawaii</option> |
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<option >daho</option> |
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<option >Illinois</option> |
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<option >Indiana</option> |
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<option >Iowa</option> |
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<option> Kansas</option> |
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<option >Kentucky</option> |
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<option >Louisiana</option> |
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<option>Maine</option> |
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<option >Maryland</option> |
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<option> Mass</option> |
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<option >Michigan</option> |
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<option >Minnesota</option> |
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<option>Mississippi</option> |
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<option>Missouri</option> |
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<option>Montana</option> |
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<option>Nebraska</option> |
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<option>Nevada</option> |
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<option>New Hampshire</option> |
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<option>New Jersey</option> |
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<option>New Mexico</option> |
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<option>New York</option> |
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<option>North Carolina</option> |
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<option>North Dakota</option> |
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<option>Ohio</option> |
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<option>Oklahoma</option> |
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<option>Oregon</option> |
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<option>Pennsylvania</option> |
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<option>Rhode Island</option> |
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<option>South Carolina</option> |
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<option>South Dakota</option> |
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<option>Tennessee</option> |
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<option>Texas</option> |
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<option> Uttah</option> |
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<option>Vermont</option> |
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<option>Virginia</option> |
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<option >Washington</option> |
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<option >West Virginia</option> |
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<option>Wisconsin</option> |
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<option >Wyoming</option> |
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</select> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Zip Code</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span> |
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<input name="zip" placeholder="Zip Code" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- Text input--> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Website or domain name</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span> |
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<input name="website" placeholder="Website or domain name" class="form-control" type="text"> |
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</div> |
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</div> |
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</div> |
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<!-- radio checks --> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Do you have hosting?</label> |
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<div class="col-md-4"> |
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<div class="radio"> |
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<label> |
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<input type="radio" name="hosting" value="yes" /> Yes |
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</label> |
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</div> |
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<div class="radio"> |
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<label> |
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<input type="radio" name="hosting" value="no" /> No |
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</label> |
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</div> |
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</div> |
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</div> |
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<!-- Text area --> |
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<div class="form-group"> |
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<label class="col-md-4 control-label">Project Description</label> |
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<div class="col-md-4 inputGroupContainer"> |
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<div class="input-group"> |
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<span class="input-group-addon"><i class="glyphicon glyphicon-pencil"></i></span> |
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<textarea class="form-control" name="comment" placeholder="Project Description"></textarea> |
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</div> |
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</div> |
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</div> |
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<!-- Success message --> |
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<div class="alert alert-success" role="alert" id="success_message">Success <i class="glyphicon glyphicon-thumbs-up"></i> Thanks for contacting us, we will get back to you shortly.</div> |
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<!-- Button --> |
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<div class="form-group"> |
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<label class="col-md-4 control-label"></label> |
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<div class="col-md-4"> |
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<button type="submit" class="btn btn-warning" >Send <span class="glyphicon glyphicon-send"></span></button> |
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</div> |
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</div> |
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</fieldset> |
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</form> |
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</div> |
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</div><!-- /.container --> |