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Server:

LiteSpeed

System:

Linux 4.18.0-553.70.1.lve.el8.x86_64

PHP Version:

8.1.33

User:

u998488001

Directory:

/home/u998488001/domains/shrital.com/public_html

Free Space:

1.81 TB

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✏️ Editing: dealer-inquiry-form.php

<?php $pg_nm="Dealer Inquiry Form"?>
	<?php $title="Dealer Inquiry Form"; ?>
	<?php $desc="Dealer Inquiry Form Distributor Proposal Form Why are you interested in becoming the distributor for Harvis Food Products"; ?>
	<?php $keywords="Shri TaL Mukhvas, Healthy Habit, Shri TaL Ajwain Mix, Shri TaL Suva Mix, Shri TaL Plain, Bidaji, Harvis Food, Inquiry Form, name, location, address, Contact Details, Email, Bank Details "; ?>
	<?php include 'include/header.php'?>
	<?php include 'include/menu.php'?>
	<?php include 'include/contacts-breadcrumb.php';?>
	<script type="text/javascript">
			window.onload();
			document.getElementById("button1").disabled = true;
			function enableBtn(){
				document.getElementById("button1").disabled = false;
			   }
		</script>
		<script src="https://www.google.com/recaptcha/api.js"></script>
		
		<div class="container p-160-cont">
			<div class="row">
				<div class="col-md-12">
					<h2 class="section-title2">Dealer Inquiry Form</h2>
					<div class="line-3-100"></div><br>
					<p class="mb-0">Distributor Proposal Form</p><br>
					<div class="tab-content">
						<div class="tab-pane fade in active" id="login-link">
						
						<form id="login-form" action="php/dealer-inquiry.php" method="POST">
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="text" name="cname" id="cname" class="form-control" placeholder="Company Name*" required>
									</div>
									<div class="col-md-6 mb-30 mb-sm-15">
										<input type="text" name="clocation" id="clocation" class="form-control" placeholder="Company Location*" required>
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="text" name="cperson" id="cperson" class="form-control" placeholder="Contact Person*" required>
									</div>
									<div class="col-md-6 mb-30">
										<input type="text" name="dob" id="dob" class="form-control" placeholder="Date of Birth with Age" required>
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="text" name="position" id="position" class="form-control" placeholder="Position with Company">
									</div>
									<div class="col-md-6 mb-30">
										<input type="text" name="qualification" id="qualification" class="form-control" placeholder="Qualification">
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-12 mb-15">
										<textarea type="text" name="address" id="address" class="form-control" placeholder="Address *"></textarea>
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="text" name="cdetailrot" id="cdetail" class="form-control" placeholder="Contact Details(R)(O)(T)**">
									</div>
									<div class="col-md-6 mb-30">
										<input type="text" name="cdetailm" id="cdetailm" class="form-control" placeholder="Contact Details(M)*">
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="email" name="email" id="email" class="form-control" placeholder="Email Address*">
									</div>
									<div class="col-md-6 mb-30">
										<input type="text" name="experience" id="experience" class="form-control" placeholder="No.of Year Experience in current Business">
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="text" name="established" id="established" class="form-control" placeholder="Type of Business and Established Date">
									</div>
									<div class="col-md-6 mb-30">
										<input type="text" name="turnover" id="turnover" class="form-control" placeholder="Company Annual Turnover(Approx) for last 3 years">
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-6 mb-15">
										<input type="text" name="vehicle" id="vehicle" class="form-control" placeholder="Vehicle">
									</div>
									<div class="col-md-6 mb-30">
										<input type="text" name="manpower" id="manpower" class="form-control" placeholder="Existing Manpower / salesman">
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-12 mb-15">
										<textarea type="text" name="interested" id="interested" class="form-control" placeholder="Why are you interested in becoming the distributor for Harvis Food Products"></textarea>
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-12 mb-15">
										<textarea type="text" name="description" id="description" class="form-control" placeholder="Brief Description of Current Business"></textarea>
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-12 mb-15">
										<textarea type="text" name="marketing" id="marketing" class="form-control" placeholder="Area of Marketing / Territory"></textarea>
									</div>
								</div>
								<div class="row mt-15">
									<div class="col-md-12 mb-15">
										<textarea type="text" name="godown" id="godown" class="form-control" placeholder="Godown Address / Warehousing Capacity (in Cubic Metres)"></textarea>
									</div>
								</div>
								<hr>
								<div class="row mt-15">
									<h3 class="h-3">Bank Details*(Name/Ac. No/IFSC)</h3>
									<div class="col-md-6  mb-15">
										<input type="text" name="bnm" id="bnm" class="form-control" placeholder="Bank Name"><br>
										<input type="text" name="accnum" id="accnum" class="form-control" placeholder="Account Number"><br>
										<input type="text" name="ifsc" id="ifsc" class="form-control" placeholder="IFSC Code">
									</div>
									<div class="col-md-6  mb-15">
										<input type="text" name="gst" id="gst" class="form-control" placeholder="GST No.">
									</div>
								</div>
								<p>Note: Please make sure that all information provided above is correct and factual. Once the form is complete. All information listed will be kept strictly confidetial between the company and applicant. It shall not be released to any third party.</p>
							
							<div class="row mb-20">
								<div class="col-sm-5"></div>
								
								<div class="col-sm-2">
								<div class="g-recaptcha" data-sitekey="6Lf9p2sUAAAAAMmei50lMpfmu1LZz0evWHMSX_zV" data-callback="enableBtn"></div>
									<br>
								<button type="submit" name="send" id= "button1" disabled="disabled" value="SEND MESSAGE" class="button small button rounded medium gray rounded btn-block text-center">Send</button>
								</div>
								<div class="col-sm-5"></div>
							</div>
							
						</form>
							
						</div>
					</div>
				</div>
			</div>
		</div>
		<?php include 'include/footer.php'?>

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