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Devil Killer Is Here MiNi Shell

MiNi SheLL

Current Path : /hermes/sb_web/sb_web/web/b1536/thelordoffloors.com/cwpaintingllc/

Linux boscustweb5002.eigbox.net 5.4.91 #1 SMP Wed Jan 20 18:10:28 EST 2021 x86_64
Upload File :
Current File : /hermes/sb_web/sb_web/web/b1536/thelordoffloors.com/cwpaintingllc/form1.php

<form method="post"  action='contactEOM.php'>
	<div class="row">
		<div class="col-sm-6 col-md-6 col-lg-4 text-left">
			<div class="form-group">
				<label for="firstname" class='t-color2 font-weight-bold'>First Name *</label>
				<input required type="text" style="width: 100%;"
									value=""
									data-msg-required="Please enter the name"
									class="form-control"
									placeholder=""
									name="firstname" id="firstname"/>
			</div>
		</div>

		<div class="col-sm-6 col-md-6 col-lg-4 text-left">
			<div class="form-group">
				<label for="lastname" class='t-color2 font-weight-bold'>Last Name *</label>
				  <input required type="text" style="width: 100%;"
									value=""
									data-msg-required="Please enter the last name"
									class="form-control"
									placeholder=""
									name="lastname" id="lastname"/>
			</div>
		</div>

		<div class="col-sm-6 col-md-6 col-lg-4 text-left">
			<div class="form-group">
				<label for="email" class='t-color2 font-weight-bold'>Email *</label>
				  <input required type="email" style="width: 100%;"
									value=""
									data-msg-required="Please enter the email"
									data-msg-email="Please enter the valid email"
									class="form-control"
									placeholder=""
									name="email"
									id="email"/>
			</div>
		</div>

		<div class="col-sm-6 col-md-6 col-lg-4 text-left">
			<div class="form-group">
				<label for="phone" class='t-color2 font-weight-bold'>Phone *</label>
				  <input required type="tel" style="width: 100%;"
									maxlength="16"
									minlength="10" 
									value=""
									data-msg-required="Please enter the phone"
									class="form-control"
									placeholder=""
									name="phone"
									id="phone"/>
			</div>
		</div>

	
		<div class="col-sm-6 col-md-6 col-lg-4 text-left">
			<div class="form-group">
				<label for="street" class='t-color2 font-weight-bold'>Street Address *</label>
				  <input required type="text" style="width: 100%;"
									value=""
									data-msg-required="Please enter the address"
									class="form-control"
									placeholder=""
									name="street" id="street"/>
			</div>
		</div>


		<div class="col-sm-6 col-md-6 col-lg-4 text-left">
			<div class="form-group">
				<label for="city" class='t-color2 font-weight-bold'>City *</label>
				  <input required type="text" style="width: 100%;"
									value=""
									data-msg-required="Please enter the city"
									class="form-control"
									placeholder=""
									name="city"
									id="city"/>
			</div>
		</div>


		<div class="col-sm-6 col-md-3 col-lg-3 text-left">
			<div class="form-group">
				<label for="state" class='t-color2 font-weight-bold'>State *</label>
				<select name="state" aria-required="true" id="state" class="form-control" style="color: black!important;" aria-invalid="false">
					<option value="AL">AL</option>
					<option value="AK">AK</option>
					<option value="AZ">AZ</option>
					<option value="AR">AR</option>
					<option value="CA">CA</option>
					<option value="CO">CO</option>
					<option value="CT">CT</option>
					<option value="DE">DE</option>
					<option value="DC">DC</option>
					<option value="FL">FL</option>
					<option value="GA">GA</option>
					<option value="HI">HI</option>
					<option value="ID">ID</option>
					<option value="IL">IL</option>
					<option value="IN">IN</option>
					<option value="IA">IA</option>
					<option value="KS">KS</option>
					<option value="KY">KY</option>
					<option value="LA">LA</option>
					<option value="ME">ME</option>
					<option value="MD">MD</option>
					<option value="MA">MA</option>
					<option value="MI">MI</option>
					<option value="MN">MN</option>
					<option value="MS">MS</option>
					<option value="MO">MO</option>
					<option value="MT">MT</option>
					<option value="NE">NE</option>
					<option value="NV">NV</option>
					<option value="NH">NH</option>
					<option value="NJ">NJ</option>
					<option value="NM">NM</option>
					<option value="NY">NY</option>
					<option value="NC">NC</option>
					<option value="ND">ND</option>
					<option value="OH">OH</option>
					<option value="OK">OK</option>
					<option value="OR">OR</option>
					<option value="PA">PA</option>
					<option value="PR">PR</option>
					<option value="RI">RI</option>
					<option value="SC">SC</option>
					<option value="SD">SD</option>
					<option value="TN">TN</option>
					<option value="TX">TX</option>
					<option value="UT">UT</option>
					<option value="VT">VT</option>
					<option value="VA">VA</option>
					<option value="WA">WA</option>
					<option value="WV">WV</option>
					<option value="WI">WI</option>
					<option value="WY">WY</option>
				</select>
			</div>
		</div>

		<div class="col-sm-6 col-md-3 col-lg-3 text-left">
			<div class="form-group">
				<label for="zip" class='t-color2 font-weight-bold'>Zip Code *</label>
				  <input required type="text" style="width: 100%;"
									value=""
									data-msg-required="Please enter the zip code"
									class="form-control"
									placeholder=""
									name="zip"
									id="zip"/>
			</div>
		</div>

		


		<div class="col-md-6 col-lg-6">

			<?php $selectServicesForm = array(
				$Info->getService(1)['title'],
				$Info->getService(2)['title'],
				'Exterior and Interior Painting',
				$Info->getService(4)['title'],
				$Info->getService(5)['title'],
				$Info->getService(6)['title'],
			); ?>

			<div class="form-group">				
				<label class="mb-0 pb-0 pt-2 t-color2 font-weight-bold" for="project">Project *</label>&emsp;					
				<select name="project" id="project" aria-required="true" class="form-control" style="color: black!important;" aria-invalid="false">
				<?php 
					for ($i = 0; $i < 5; $i++){
						?>
							<option value="<?php echo $selectServicesForm[$i];?>"><?php echo $selectServicesForm[$i];?></option>
						<?php 
					}
				?>
				</select>				
			</div>
		</div>

		<div class="col-sm-6 col-md-6 col-lg-6 text-left">
			<div class="form-group">
				<label for="subject" class='t-color2 font-weight-bold'>Subject *</label>
				  <input required type="text" style="width: 100%;"
									value=""
									data-msg-required="Please enter the subject"
									class="form-control"
									placeholder=""
									name="subject"
									id="subject"/>
			</div>
		</div>

		<div class="col-md-4 col-lg-6">
			<div class="form-group">
				
				<label class="mb-0 pb-0 pt-2 t-color2 font-weight-bold" for="promotions">I am interested in receiving promotions and information. *</label>&emsp;					
				<select name="promotions" id="promotions" aria-required="true" class="form-control" style="color: black!important;" aria-invalid="false">
					<option value="Yes">Yes</option>
					<option value="No">No</option>
				</select>
				
			</div>	
		</div>

	</div>


	<div class="row">
		<div class="col-md-12">
		<label class="mb-0 pb-0 pt-2 t-color2 font-weight-bold">Your Message. <span class="required">*</span></label>
			<div class="form-group">
					<textarea style="width: 100%;"
					data-msg-required="Please enter the message"
					require
					rows="2"
					class="form-control"
					name="message"
					placeholder="Message"
					id="message"></textarea>
			</div>
		</div>
	</div>

	<input type="text" id="fullname" name="fullname" hidden>
	
	<input type="hidden" name="token" value="<?php echo $_SESSION['token'];?>">

	<div class="row">
		<div class="col-md-6 mx-auto text-center">
			<div class="form-group t-color2 font-weight-bold">
				Write the code - <img src="captcha.php" width="60" />
				<input name="captcha" class="form-control" type="text" required>
			</div>
		</div>
		<div class="col-md-12 text-center">			
			<center><span class="badge badge-light text-dark badge-sm"><strong>Note: All the Fields are Required</strong></span></center>
		</div>
		<div class="col-md-12 text-center">			
			<center>
				<input type="submit" value="Send Message" id="submit-contact" class="btn btn-lg btn-danger" data-loading-text="Loading..."/>
			</center>
		</div>
	</div>
</form>

Creat By MiNi SheLL
Email: devilkiller@gmail.com