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quote-2.php
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quote-2.php
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<?
$title = "GIC Medical Disposal - Premium Medical Disposal Service";
$desc = "We are Canada's Medical Disposal company dedicated to providing compliant, efficient and personalized unparalleled solutions tailored to any client's needs.";
?>
<?php include 'components/header.php'; ?>
<script type="text/javascript">
var RecaptchaOptions = {
theme : 'custom',
custom_theme_widget: 'recaptcha_widget'
};
</script>
<style type="text/css">
input.parsley-success, textarea.parsley-success {
color: #468847 !important;
background-color: #DFF0D8 !important;
border: 1px solid #D6E9C6 !important;
}
input.parsley-error, textarea.parsley-error {
color: #B94A48 !important;
background-color: #F2DEDE !important;
border: 1px solid #EED3D7 !important;
}
</style>
<div class="shadow mainImage center mgnT14" style="background-image: url(img/waste.jpg);"></div>
<br>
<div class="clear"></div>
<div class="contentBox">
<div class="contentLeft">
<h1>Request a Free Quote</h1>
<div class="lineRuleSolid"></div>
<div id="left">
<p>Want to experience the GIC advantage? Contact us today for a no-obligation quote. Have Questions? We would like to hear from you.</p>
<p><strong>Feel free to email us at <a href="mailto:<?= $to_email; ?>"><?= $to_email; ?></a>, call us toll free at
<?= $to_phone; ?>, or fill out the form below.</strong></p>
<p>You may also choose to use our contact form. Simply fill in the fields below and one of GIC Medical Disposal’s experts will respond to you in a timely fashion. Please ensure that all necessary fields are completed to help us contact you promptly. Your information is private and is only used as a point of contact. </p>
<div class="contact">
<form id="form1" name="form1" data-validate="parsley" method="post" action="formmail">
<input type="hidden" name="env_report" value="REMOTE_HOST,REMOTE_ADDR,HTTP_USER_AGENT,AUTH_TYPE,REMOTE_USER" />
<input type="hidden" name="csvfile" value="formdata.csv" />
<input type="hidden" name="csvcolumns" value="Email,Name,Phone,Message" />
<input type="hidden" name="recipients" value="[email protected]" />
<input type="hidden" name="lead_source" value="<?= $source; ?>" />
<input type="hidden" name="good_url" value="Thank-You.php" />
<input type="hidden" name="bad_url" value="Sorry.php" />
<input type="hidden" name="subject" value="Free Quote Request" />
<input type="hidden" name="derive_fields" value="imgverify=recaptcha_response_field,email=Email,realname=Name" />
<input type="hidden" name="mail_options" value="Exclude=Email;Name" />
<table border="0">
<tr>
<td><input placeholder="email address" type="text" size="31" id="Email" name="Email" value="" data-trigger="change" data-required="true" data-type="email"></td>
</tr>
<tr>
<td><input placeholder="Name" type="text" size="31" name="Name" value="" data-required="true"></td>
</tr>
<tr>
<td><input placeholder="Phone Number" type="text" size="31" name="Phone" value="" data-required="true" data-trigger="change" data-type="number"></td>
</tr>
<tr>
<td><textarea placeholder="Message" cols="31" rows="2" name="Message" data-trigger="keyup" data-rangelength="[0,200]"></textarea></td>
</tr>
<tr>
<td align="left">
<span style="font-family:Arial, Helvetica, sans-serif; color:grey; font-size:11px;"> Anti-spam: what's <span id="num1"></span> + <span id="num2"></span>?</span>
<input style="margin-left:10px; width:42px; margin-bottom:5px;" type="text" id="sum" maxlength="80" name="sum" size="4" />
<script type="text/javascript" language="javascript">
var num1=Math.floor(Math.random()*11);
var num2=Math.floor(Math.random()*11);
document.getElementById("num1").innerHTML = num1;
document.getElementById("num2").innerHTML = num2;
function checkAdd() {
f = document.form1;
var sum = parseInt(f.sum.value);
if (sum == (num1+num2)) {
f.action="maily";
f.submit();
} else {
alert("Incorrect number, please check the anti-spam field.");
}
}
</script>
</td> </tr>
<tr>
<td align="center">
<input onclick="checkAdd();" class="bigGreenButton ac" type="submit" value="GET A FREE QUOTE">
</td>
</tr>
</table>
</form>
</div>
</div>
<br>
<div class="clear"></div>
</div>
<?php include 'components/rightAlt.php'; ?>
<?php include 'components/footer.php'; ?>