templates/modal-bill.html.twig line 1

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  1. <div class="modal fade" id="modalBill" tabindex="-1" aria-labelledby="modalBillLabel" aria-hidden="true">
  2.     <div class="modal-dialog modal-lg">
  3.         <div class="modal-content">
  4.             <div class = "row align-items-stretch">
  5.                 <div class = "col-12 col-md-5  d-none d-md-block">
  6.                     <div class = "modal-contact-img-container">
  7.                     
  8.                         <div class = "modal-contact-img">
  9.                         </div>
  10.                     </div>
  11.                     
  12.                 </div>
  13.                 <div class = "col-12 col-md-7 p-0 modal-contact-form-container ">
  14.                     <div class = "text-end">
  15.                         <a class = "close-modal-ico" href = "#" type="button" class="close" data-dismiss="modal" aria-label="Close" onclick = "closeModalBill()" >
  16.                             <span aria-hidden="true">&times;</span>
  17.                         </a>
  18.                     </div>
  19.                     <div class = "modal-contact-title text-center text-md-start">
  20.                         Conviértete en nuestro socio
  21.                     </div>
  22.                     <form id = "modal-bill-form" action="{{path('homepage_contact_send')}}" >
  23.                         <input type = "hidden" id = "from2" name = "from2" />
  24.                         <div class='row'>
  25.                             <div class='col-12'>
  26.                                 <div class="form-group">
  27.                                     <label for = "name" >Nombre y Apellido <span>*</span></label>
  28.                                     <br>
  29.                                     <input id = "name" name = "name" type = "text" class = "personalized-input" />
  30.                                 </div>
  31.                             </div>
  32.                         </div>
  33.                         <div class='row'>
  34.                             <div class='col-12'>
  35.                                 <div class="form-group">
  36.                                     <label for = "country" >País<span>*</span></label>
  37.                                     <br>
  38.                                     <select id = "country"  name = "country"  class = "personalized-select" >
  39.                                         <option {% if cid == 1 %} selected="selected" {% endif %} value="Guatemala">Guatemala</option>
  40.                                         <option {% if cid == 2 %} selected="selected" {% endif %}value="El Salvador">El Salvador</option>
  41.                                         <option {% if cid == 5 %} selected="selected" {% endif %} value="Costa Rica">Costa Rica</option>
  42.                                         <option {% if cid == 6 %} selected="selected" {% endif %} value="Panama">Panama</option>
  43.                                         <option {% if cid == 7 %} selected="selected" {% endif %} value="República Dominicana">República Dominicana</option>
  44.                                     </select>
  45.                                 </div>
  46.                             </div>
  47.                         </div>
  48.                         <div class='row'>
  49.                             <div class='col-12'>
  50.                                 <div class="form-group">
  51.                                     <label for = "phone" >Teléfono<span>*</span></label>
  52.                                     <br>
  53.                                     <input id = "phone" name = "phone" required type = "text" class = "personalized-input" />
  54.                                 </div>
  55.                             </div>
  56.                         </div>
  57.                         <div class='row'>
  58.                             <div class='col-12'>
  59.                                 <div class="form-group">
  60.                                     <label for = "email" >Correo Electrónico<span>*</span></label>
  61.                                     <br>
  62.                                     <input id = "email" name = "email" required type = "text" class = "personalized-input" />
  63.                                 </div>
  64.                             </div>
  65.                         </div>
  66.                         <div class = "form-group mb-5 text-start">
  67.                             <div class="g-recaptcha " 
  68.                             data-sitekey="6LfTGV0qAAAAAN5XajzFNRTNW2gbGNYeiHLQfimp"></div>
  69.                         </div>
  70.                         
  71.                         <div class='row'>
  72.                             <div class='col-12'>
  73.                                 <div class="form-group">
  74.                                     <button type = "submit" class="btn btn-warning-custom-modal" >
  75.                                         Enviar
  76.                                     </button>
  77.                                 </div>
  78.                             </div>
  79.                         </div>
  80.                         
  81.                     </form>
  82.                 </div>
  83.             </div>
  84.             
  85.         
  86.             
  87.         </div>
  88.     </div>
  89. </div>