Your IP : 3.135.196.144


Current Path : /home/church/public_html/comparefloridarates.com/
Upload File :
Current File : /home/church/public_html/comparefloridarates.com/form-shell.php

            
                 
            <script type="text/javascript" src="scripts/carrier-ticker.js"></script> 
  <script type="text/javascript">
		$(function(){
			$('#carrier-list').totemticker({
				row_height	:	'150px',
				mousestop	:	true,
			});
		});
	</script> 
            <div class="form-shell">

            <? if ($page_title!=$page_title_contact) { ?>
              <div class="widget">
                <h4>Contact Us</h4>
                
                <div class="widget-rule"></div>
                <center>
                <div class="widget-form">
                  <form method="post" action="contact.php" id="widget-form" class="form-horizontal">
                    <div class="widget-row">
                      <div class="field">

                        <input name="Name" type="text" class="input-medium required" id="Name" placeholder="NAME">
                      </div>
                    </div>
                    <div class="widget-row">
                      <div class="field">

                        <input name="Phone" type="text" class="input-medium" id="Phone" placeholder="PHONE">
                      </div>
                    </div>
                    <div class="widget-row">
                      <div class="field">

                        <input name="Email" type="text" class="input-medium" id="Email" placeholder="EMAIL">
                      </div>
                    </div>
                    <div class="widget-row">
                      <div class="field">

                        <textarea class="input-large" name="Comments" id="Comments" rows="7"></textarea>
                      </div>
                    </div>
                    <div class="clear"></div>
                    <div style="padding: 5px 0 0 20px; margin-left:-20px;">
                      <button type="submit" id="submit" class="btn btn-small" value="Submit" onclick="submitForm();return false;">Submit</button>
                      <button type="reset" class="btn btn-small">Cancel</button>
                    </div>
                  </form>
                </div>
                </center>
              </div>
              <!--{ end widget -->
              <? } else { ?>
              <? } ?>

           
    
              <div class="clear"></div>
              
              
              <div style="clear:both;"></div>
            </div>
            <!--end form-shell-->    
            <div style="clear:both;"></div>