<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: Please add the following <META> element to your page <HEAD>. -->
<!-- If necessary, please modify the charset parameter to specify the -->
<!-- character set of your HTML page. -->
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<html>
<head>
<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="shortcut icon" href="https://www.polysciences.com/favicon.ico">
<title>Contact Us | Polysciences</title>
<link href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.6/css/bootstrap.min.css" rel="stylesheet" />
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.11.3/jquery.min.js"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.6/js/bootstrap.min.js"></script>
<script>
$.validator.setDefaults({
highlight: function (element) {
$(element).closest('.form-group').addClass('has-error');
},
unhighlight: function (element) {
$(element).closest('.form-group').removeClass('has-error');
},
errorElement: 'span',
errorClass: 'help-block',
errorPlacement: function (error, element) {
if (element.parent('.input-group').length) {
error.insertAfter(element.parent());
} else {
error.insertAfter(element);
}
}
});
$(document).ready(function () {
$("#contact_form").validate();
});
</script>
<style>
body {
width: 800px;
margin-left: auto;
margin-right: auto;
}
</style>
</head>
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: Please add the following <FORM> element to your page. -->
<!-- ---------------------------------------------------------------------- -->
<body>
<form action="https://test.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST">
<input type=hidden name="oid" value="00D3K0000008kFJ">
<input type=hidden name="retURL" value="https://www.polysciences.com/default/contact-us/">
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: These fields are optional debugging elements. Please uncomment -->
<!-- these lines if you wish to test in debug mode. -->
<!-- <input type="hidden" name="debug" value=1> -->
<!-- <input type="hidden" name="debugEmail" -->
<!-- value="vishal.anand@girikon.com"> -->
<!-- ---------------------------------------------------------------------- -->
<div class="">
</br>
<!--<div class="" style="text-align: center;">
<img alt="Speedcrafts" src="https://speedcrafts.com/wp-content/uploads/2018/05/logo-2.png" width=150"
height="70">
</div>-->
</div>
<div class="row">
<div class="col-xs-12 col-md-12">
<div class="panel panel-default">
<div class="panel-heading">
<span class="glyphicon glyphicon-earphone" style="font-size:16px;" aria-hidden="true"></span>
<strong>Contact Form</strong>
</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-6 col-md-6">
<div class="form-group">
<label for="first_name">First Name: <span style="color:red;">*</span></label>
<input id="first_name" maxlength="40" name="first_name" size="20" type="text"
class="form-control" required />
</div>
</div>
<div class="col-xs-6 col-md-6">
<div class="form-group">
<label for="last_name">Last Name: <span style="color:red;">*</span></label>
<input id="last_name" maxlength="80" name="last_name" size="20" type="text"
class="form-control" required />
</div>
</div>
</div>
<div class="row">
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="company">Company/Organization: <span style="color:red;">*</span></label>
<input id="company" maxlength="40" name="company" size="20" type="text"
class="form-control" required/>
</div>
</div>
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="title">Professional Title:</label>
<input id="title" maxlength="40" name="title" size="20" type="text"
class="form-control" />
</div>
</div>
<div class="col-xs-4 col-md-4">
<div class="form-group" id="webform">
<label for="email">Email: <span style="color:red;">*</span></label>
<input id="email" maxlength="80" name="email" size="20" type="text"
class="form-control" required="true" required pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,}$"
title="username@example.com"/>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="phone">Phone: <span style="color:red;">*</span></label>
<input id="phone" maxlength="40" name="phone" size="20" type="text"
class="form-control" required/>
</div>
</div>
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="fax">Fax: </label>
<input id="fax" maxlength="40" name="fax" size="20" type="text"
class="form-control" />
</div>
</div>
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="street">Address: <span style="color:red;">*</span></label>
<textarea name="street" class="form-control" style="max-width: 100%;" required></textarea>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="city">City: <span style="color:red;">*</span></label>
<input id="city" name="city" type="text" class="form-control" required/>
</div>
</div>
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="state">State: <span style="color:red;">*</span></label>
<input id="state" name="State" type="text" class="form-control" required/>
</div>
</div>
<div class="col-xs-4 col-md-4">
<div class="form-group">
<label for="zip">Zip/Postal Code: <span style="color:red;">*</span></label>
<input id="zip" maxlength="20" name="zip" size="20" type="text" required class="form-control"/>
</div>
</div>
</div>
<!-- <div class="row">
<div class="col-xs-6 col-md-6">
<div class="form-group">
<label for="city">City </label>
<input id="city" name="city" type="text" class="form-control" />
</div>
</div>
<div class="col-xs-6 col-md-6">
<div class="form-group">
<label for="state">State </label>
<input id="state" name="State" type="text" class="form-control" />
</div>
</div>
</div>-->
<div class="row">
<div class="col-xs-12 col-md-12">
<div class="form-group" >
<label for="description">Question/Comment: </label>
<textarea name="description" style="max-width: 100%;" class="form-control"></textarea>
</div>
</div>
</div>
<div>
<input type="hidden" id="lead_source" name="lead_source" value="web" />
</div>
<div class="row">
<div class="col-xs-12 col-md-12" style="text-align: center;">
<div class="form-group">
<input class="btn btn-primary"
type="submit" name="submit" />
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</body>
</html>