File size: 1.47Kb
{include file="modules/contacts.tpl"}
<div class="block">
{include file="modules/map.tpl"}
</div>
<div class="block story">
<h4 class="title">Feedback</h4>
<ul class="ui-form">
[not-logged]
<li class="form-group combo">
<div class="combo_field"><input placeholder="Your name" type="text" maxlength="35" name="name" id="name" class="wide" required></div>
<div class="combo_field"><input placeholder="Your e-mail" type="email" maxlength="35" name="email" id="email" class="wide" required></div>
</li>
[/not-logged]
<li class="form-group">
<label>To {recipient}</label>
</li>
<li class="form-group">
<input placeholder="Topic" type="text" maxlength="45" name="subject" id="subject" class="wide" required>
</li>
<li class="form-group">
<textarea placeholder="Message" name="message" id="message" rows="8" class="wide" required></textarea>
</li>
[recaptcha]
<li class="form-group">{recaptcha}</li>
[/recaptcha]
[question]
<li class="form-group">
<label for="question_answer">Question: {question}</label>
<input placeholder="Answer" type="text" name="question_answer" id="question_answer" class="wide" required>
</li>
[/question]
</ul>
<div class="form_submit">
[sec_code]
<div class="c-capcha">
{code}
<input placeholder="Enter the code" title="Enter the code" type="text" name="sec_code" id="sec_code" required>
</div>
[/sec_code]
<button class="btn" type="submit" name="send_btn"><b>Send</b></button>
</div>
</div>