gistfile1.haml

= render :partial => "shared/sidebar_nav"
#about.static
  .page-header
%h1 Please complete this form and submit it. Our CouponTrade team will connect with you regarding your order within 1 business day.
%section.content 
  .container
  %h4 Please complete this form and submit it. Our CouponTrade team will connect with you regarding your order within 1 business day.
.billing-shipping-container
.billing
		%h3 Billing Information
		.date-cust
			.billingDate
				%label.textLabel{:for => "billingDate"} Date
				%input#billingDate.textInput{:name => "billingDate", :type => "text"}/
			.custNumber
				%label.textLabel{:for => "custNumber"} Cust.#
				%input#custNumber.textInput{:name => "custNumber", :type => "number"}/
	.clear
	%label.textLabel{:for => "billingCompany"} Company
	%input#billingCompany.textInput{:name => "billingCompany", :type => "text"}/
	%label.textLabel{:for => "billingAddress"} Address:
	%input#billingAddress.textInput{:name => "billingAddress", :type => "text"}/
	%label.textLabel{:for => "billingCity"} City:
	%input#billingCity.textInput{:name => "billingCity", :type => "text"}/
	.billState
		%label.textLabel{:for => "billingState"} State:
		%input#billingState.textInput{:name => "billingState", :type => "text"}/
	.billZip
		%label.textLabel{:for => "billingZip"} Zip:
		%input#billingZip.textInput{:name => "billingZip", :type => "text"}/
	.clear
	.billPhone
		%label.textLabel{:for => "billingPhone"} Phone:
		%input#billingPhone.textInput{:name => "billingPhone", :type => "text"}/
	.billFax
		%label.textLabel{:for => "billingFax"} FAX:
		%input#billingFax.textInput{:name => "billingFax", :type => "text"}/
		%label.textLabel{:for => "billingEmail"} E-Mail Address:
		%input#billingEmail.textInput{:name => "billingEmail", :type => "email"}/  
	.billing-shipping
		%h3 Shipping Information
			%label.textLabel{:for => "shippingName"} Name
			%input#shippingName.textInput{:name => "shippingName", :type => "text"}/
			%label.textLabel{:for => "shippingCompany"} Company
			%input#shippingCompany.textInput{:name => "shippingCompany", :type => "text"}/
			%label.textLabel{:for => "shippingAddress"} Address
			%input#shippingAddress.textInput{:name => "shippingAddress", :type => "text"}/
			%label.textLabel{:for => "shippingCity"} City
			%input#shippingCity.textInput{:name => "shippingCity", :type => "text"}/
		.shipState
			%label.textLabel{:for => "shippingState"} State
			%input#shippingState.textInput{:name => "shippingState", :type => "text"}/
		.shipZip
			%label.textLabel{:for => "shippingZip"} Zip
			%input#shippingZip.textInput{:name => "shippingZip", :type => "text"}/
			%label.textLabel{:for => "shippingPhone"} Phone
			%input#shippingPhone.textInput{:name => "shippingPhone", :type => "text"}/
	.clear
	.bottom-form
		%h3 Is This For:
			%input{:name => "employeeIncentives", :type => "checkbox", :value => "employeeIncentives"}
			%label.textlabel{:for => "employeeIncentives"} Employee Incentives
			%input{:name => "corporateLoyalty", :type => "checkbox", :value => "corporateLoyalty"}
			%label.textlabel{:for => "corporateLoyalty"} Corporate Loyalty Program*
			%input{:name => "nonProfit", :type => "checkbox", :value => "nonProfit"}
			%label.textlabel{:for => "nonProfit"} Non-Profit Fundraiser
			%input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
			%label.textlabel{:for => "corporateGifting"} Corporate Gifting
		%h3 Giftcard(s) - Tell us more about your bulk gift card purchase.
			%textarea.textInput.inputbox{:name => "name", :row => "2"}
		%h3 Payment Method
		.payBycheck
				%input{:name => "employeeIncentives", :type => "checkbox", :value => "employeeIncentives"}
				%label.textlabel{:for => "employeeIncentives"} Check
		.payableTo
			%p
				%strong Payable to:
			%p CouponTrade, Inc.
			%p 214 West Ohio Street, Suite 4
			%p Chicago, IL 60654
		.payment-side
			%input{:name => "corporateLoyalty", :type => "checkbox", :value => "corporateLoyalty"}
			%label.textlabel{:for => "corporateLoyalty"} **Credit Card
			%br
		  %input{:name => "nonProfit", :type => "checkbox", :value => "nonProfit"}
		  %label.textlabel{:for => "nonProfit"} Visa
		  %input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
		  %label.textlabel{:for => "corporateGifting"} MC
		  %input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
		  %label.textlabel{:for => "corporateGifting"} AMEX
		  %input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
		  %label.textlabel{:for => "corporateGifting"} DISCOVER
			%p Last Four Digits of Credit Card #:
		.clear
		.requested-brands
			%h3	Requested Brands               Unit Cost    X    Quantity = Total
				.reqBrand
				%input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
				.reqBrand
				  %input#reqBrand.textInput{:name => "reqBrand", :type => "text"}/
				.unitCost
				  %input#unitCost.textInput{:name => "unitCost", :type => "text"}/
				.quantity
				  %input#quantity.textInput{:name => "quantity", :type => "number"}/
				.brandTotal
				  %input#brandTotal.textInput{:name => "brandTotal", :type => "text"}/
					%br
					%br
					%br
				.contact-information
				  %p COUPONTRADE CONTACT:
				  %p P. 888-838-5847
				  %p F. 312-929-4666
				  %p E. bulk@coupontrade.com
				.subtotal
				  %p SUBTOTAL = ____________
					%br
					%p
						3.5% PROCESSING FEE
					%br
					%br
					%br
					%br
						(FOR ORDERS $5000 OR LESS) = ____________
					%br
					%p SHIPPING = ____________
					%br
					%p TOTAL = 
					%br
					.clear