[include css('forms.css')];

[html-page set-title("Request A Quote")];


<div id="product-container">
	<h2>Request a Quote</h2>
	<h3>Customer Information</h3>
	<p>
		Please fill out the form below to request a quote for a product. Once received, a KPI
		representative will contact you to get any additional information required to provide you
		with a quote.
	</p>

	<div style='display: [var error-display];' class='error-group'>
		[var error-message];
	</div>

	<form method='post' action="" id="contact-form" style='display: [var form-display];'>
		<input type="hidden" name="submitted" value="1">
		<input type="hidden" name="formType" value="quote">
		<input type="hidden" name="language" value="English">

		<table>
			<tr class='row'>
				<td class='group'>
					<label for='wholename'>Name:</label>
					<input type="text" name='name' id='wholename' class='std-field' value="[var name];">
				</td>

				<td class='group'>
					<label for='company'>Company:</label>
					<input type="text" name='company' id='company' class='std-field' value="[var company];">
				</td>
			</tr>

			<tr class='row'>
				<td class='group'>
					<label for='phone'>Phone:</label>
					<input type="text" name='phone' id='phone' class='std-field' value="[var phone];">
				</td>


				<td class='group'>
					<label for='fax'>Fax:</label>
					<input type="text" name='fax' id='fax' class='std-field' value="[var fax];">
				</td>

				<td class='group'>
					<label for='email'>Email:</label>
					<input type="text" name='from' id='email' class='std-field' value="[var from];">
				</td>
			</tr>

			<tr class='row'>

				<td class='group'>
					<label for='address'>Address:</label>
					<input type="text" name='address' id='address' class='std-field' value="[var address];">
				</td>

				<td class='group'>
					<label for='state'>State:</label>
						<select name="state" id='state' title='State' class='std-field'>
							[htmlpage select-options('[var state];', '', [var state-option-params];)];
						</select>
				</td>

				<td class='group'>
					<label for='zip'>Zip:</label>
					<input type="text" name='zip' id='zip' class='std-field' value="[var zip];">
				</td>
			</tr>
			
			<tr class="row">
				<td class='group'>
					<label for='international'>International Countries:</label>
					<input type="text" name='international' id='international' class='std-field' value="[var international];">
				</td>
			</tr>
		</table>

		<h3>Product Request Information</h3>
		<table>
			<tr class='row'>
				<td class='group'>
					<label for='manufacturer'>Manufacturer:</label>
					<input type="text" name='manufacturer' id='manufacturer' class='std-field' value="[var manufacturer];">
				</td>

				<td class='group'>
					<label for='categories'>Categories:</label>
					<input type="text" name='categories' id='categories' class='std-field' value="[var categories];">
				</td>

				<td class='group'>
					<label for='product'>Product:</label>
					<input type="text" name='product' id='product' class='std-field' value="[var product];">
				</td>

			</tr>

			<tr class='row'>
				<td colspan="3"class='group'>
					<label for='notes'>Parts &amp; Service Request:</label><br/>
					<textarea name="additional-interests" id="notes" rows="5" class="std-field" style="width:521px;">[var additional-interests];</textarea>
				</td>
			</tr>


			<tr class='row'>
				<td  colspan="3" class='group'>
					<label for='notes'>Notes <br/>(If Any):</label>
					<textarea name="notes" id="notes" rows="5" class="std-field" style="width:521px;">[var notes];</textarea>
				</td>
			</tr>


		</table>
		<div class="field">
			<INPUT type='image' name="submit" src="/images/contact/submit.gif" title="Submit" alt='submit' class="actionbtn">
			<INPUT type='image' src="/images/contact/reset.gif" title="reset" alt='reset' class='otherbtn'
			onclick='(document.getElementById("contact-form")).reset(); return false;'>
		</div>

	</form>
	<div style='display: [var notice-display];' class='error-group'>
		<p>To prevent spam, you may only sumbit an application once every 5 minutes.  You will
		be able to submit another application at <em>[var notice-open-time];</em>.
		</p>
	</div>
	<div class="float-catch"></div>
</div>