File size: 1.92Kb
<div class="block story shadow">
<div class="wrp clrfix">
<div class="head">
<h1 class="title h2 ultrabold">Feedback</h1>
</div>
<div class="feedback clrfix">
<div class="grid_1_4 right grid_last">
<b>Adresse</b><br>
660093, Krasnoyarsk, Kapitanskaya st., 12, office 43<br>
<br>
<b>Telefon</b><br>
8 (391) <b>217-99-79</b><br>
</div>
<div class="grid_3_4">
<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</label>
{recipient}
</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"[not-logged] style="height: 140px;"[/not-logged] 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 class="ultrabold">Send</b></button>
</div>
</div>
</div>
</div>
</div>
{include file="modules/map.tpl"}