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apply.php
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apply.php
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<?php $page = "apply"; ?>
<?php
//include header.php
include_once('includes/header.php');
?>
<div id="content_products" class="container">
<h2>Apply</h2>
<div class="divider"></div>
<div class="span8" id="Apply">
<form>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_PRODUCT'] ?>:</label>
<div class="span4">
<select>
<option disabled="disabled">--Select--</option>
<option>ATM's</option>
<option>Cash Drawers</option>
<option>Touch Terminals</option>
<option>eCommerce Software</option>
<option>Prepaid Mastercard</option>
<option>P.O.S.</option>
</select>
</div>
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_COMPANY_NAME'] ?></label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_DHA_NAME'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_MAILING_ADDRESS'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_CITY'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_STATE'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_ZIP'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_BUSINESS_PHONE'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_FAX'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_COMPANY_WEBSITE'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_PROVIDER_QUESTION'] ?></label>
<div class="span4 row">
<div class="span1">
<input type="radio" name="Yes" value="Yes" class="radio" /> <br><?php echo $lang['APPLY_PROVIDER_QUESTION_YES'] ?>
</div>
<div class="span1">
<input type="radio" name="No" value="No" class="radio" /> <br><?php echo $lang['APPLY_PROVIDER_QUESTION_NO'] ?>
</div>
</div>
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_PROVIDER_QUESTION_BOOL'] ?></label><br>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_CONTACT_NAME'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_CONTACT_PHONE'] ?>:</label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_CONTACT_EMAIL'] ?>: </label>
<input class="span4 apply">
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_BEST_TIME_TO_CALL'] ?>:</label>
<div class="span4 row">
<div class="span1">
<input type="radio" name="Yes" value="Yes" class="radio" /> <br><?php echo $lang['APPLY_BEST_MORNING'] ?>
</div>
<div class="span1">
<input type="radio" name="No" value="No" class="radio" /> <br><?php echo $lang['APPLY_BEST_AFTERNOON'] ?>
</div>
<div class="span1">
<input type="radio" name="No" value="No" class="radio" /> <br><?php echo $lang['APPLY_BEST_EVENING'] ?>
</div>
</div>
</div>
<div class="row">
<label class="span3"><?php echo $lang['APPLY_QUESTIONS'] ?></label>
<textarea class="span4 apply"></textarea>
</div>
<div class="row" id="recaptcha_widget">
<div class="span6">
<div class="span3" id="recaptcha_image"></div>
<div class="recaptcha_only_if_incorrect_sol" style="color:red"><?php echo $lang['CAPTCHA_ERROR'] ?></div>
<span class="recaptcha_only_if_image"><?php echo $lang['CAPTCHA_ENTER_WORDS'] ?>:</span>
<span class="recaptcha_only_if_audio"><?php echo $lang['CAPTCHA_ENTER_AUDIO'] ?>:</span>
</div>
<div class="span4">
<input type="text" id="recaptcha_response_field" name="recaptcha_response_field" />
<div>
<a href="javascript:Recaptcha.reload()"><?php echo $lang['CAPTCHA_GET_ANOTHER_WORD'] ?>:</a>
</div>
<div class="recaptcha_only_if_image">
<a href="javascript:Recaptcha.switch_type('audio')"><?php echo $lang['CAPTCHA_GET_AUDIO'] ?></a>
</div>
<div class="recaptcha_only_if_audio">
<a href="javascript:Recaptcha.switch_type('image')"><?php echo $lang['CAPTCHA_GET_IMAGE'] ?></a>
</div>
<div>
<a href="javascript:Recaptcha.showhelp()"><?php echo $lang['CAPTCHA_HELP'] ?></a>
</div>
</div>
</div>
<script type="text/javascript"
src="http://www.google.com/recaptcha/api/challenge?k=6Lfzf8wSAAAAAMAOrVDKpHhcvCf4GkqQp3DNWydB">
</script>
<noscript>
<iframe src="http://www.google.com/recaptcha/api/noscript?k=6Lfzf8wSAAAAAMAOrVDKpHhcvCf4GkqQp3DNWydB"
height="300" width="500" frameborder="0"></iframe><br>
<textarea name="recaptcha_challenge_field" rows="3" cols="40">
</textarea>
<input type="hidden" name="recaptcha_response_field"
value="manual_challenge">
</noscript>
<input type="submit" class="btn danger" value="<?php echo $lang['APPLY_SUBMIT'] ?>">
</form>
</div>
</div>
<?php
//include footer.php
include_once('includes/footer.php');
?>