489495df
MSV FM
MSV FM
<div>
<div class="mt-4 mb-4 text-center loader hidden"><img src="images/loader.gif" /></div>
<div class="notif-message"></div>
<form action="sendmail.php" method="POST" id="requestQoute">
<input type="hidden" name="form_type" value="2">
<div class="row">
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="first_name">First Name*</label>
<input type="text" class="form-control" name="first_name" required>
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="last_name">Last Name*</label>
<input type="text" class="form-control" name="last_name" required>
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="email">Email*</label>
<input type="email" class="form-control" name="email" required>
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="company_name">Company Name</label>
<input type="text" class="form-control" name="company_name">
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="phone">Phone*</label>
<input type="text" class="form-control" name="phone" required>
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="choose_course">Choose a course*</label>
<select name="choose_course" class="form-control" required>
<option value="" disabled=""></option>
<option value="Basic Life Support" >Basic Life Support</option>
<option value="Medication">Medication</option>
<option value="Infection Control">Infection Control</option>
<option value="Communication">Communication</option>
<option value="Equality & Diversity">Equality & Diversity</option>
<option value="Health & Safety">Health & Safety</option>
<option value="Moving & Handling">Moving & Handling</option>
<option value="Safeguarding Adults">Safeguarding Adults</option>
<option value="Safeguarding Children">Safeguarding Children</option>
<option value="Dementia Awareness">Dementia Awareness</option>
<option value="Fluids & Nutrition">Fluids & Nutrition</option>
<option value="Understand your Role">Understand your Role</option>
<option value="Duty of Care">Duty of Care</option>
<option value="COSHH">COSHH</option>
<option value="Other">Other</option>
</select>
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="chosen_date">Date*</label>
<input type="date" class="form-control" name="chosen_date" required>
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="chosen_time">Time</label>
<input type="text" id="timeInput" class="form-control" name="chosen_time">
</div>
</div>
<div class="col-12 col-sm-6 col-lg-4">
<div class="form-group">
<label for="chosen_day">Day</label>
<select class="form-control" name="chosen_day">
<option value="Sunday">Sunday</option>
<option value="Monday">Monday</option>
<option value="Tuesday">Tuesday</option>
<option value="Wednesday">Wednesday</option>
<option value="Thursday">Thursday</option>
<option value="Friday">Friday</option>
<option value="Saturday">Saturday</option>
</select>
</div>
</div>
<div class="col-12">
<div class="form-group">
<label for="address_detail">Address Detail</label>
<input type="text" class="form-control" name="address_detail">
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<label for="description">Brief Description</label>
<textarea name="description" class="form-control" rows="5"></textarea>
</div>
</div>
</div>
<div class="text-center">
<input type="submit" name="submit" value="submit" class="btn btn-primary">
</div>
</form>
</div>