39 lines
976 B
Plaintext
39 lines
976 B
Plaintext
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<form method="POST" action="affinitylive.php">
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<fieldset class="checkbox">
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<legend>I need:</legend>
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<label>
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<input type="checkbox" name="selection[]" value="quote">
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A Quote
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</label>
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<label>
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<input type="checkbox" name="selection[]" value ="help">
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Help
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</label>
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</fieldset>
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<fieldset class ="user-input">
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<legend>Contact Info:</legend>
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<input type="text" name="company_name" class="input" placeholder="Company Name">
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<input type="text" name="contact_firstname" class="input" placeholder="First Name">
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<input type="text" name="contact_surname" class="input" placeholder="Last Name">
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<input type="email" name="email" class="input" placeholder="Email">
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<input type="tel" name="phone_number" class="input" placeholder="Phone Number">
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<div><button name="submit">Submit</button></div>
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</fieldset>
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</form>
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