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Edit: /home/u523034047/domains/amanelectronic.com/public_html/enquiry.php

<!DOCTYPE html>
<html>

<meta http-equiv="content-type" content="text/html;charset=UTF-8" />
<head>
    <meta charset="utf-8">
    <title> Contact Us</title>
    
    <link href="css/bootstrap.css" rel="stylesheet">
    <link href="css/style.css" rel="stylesheet">
    
    <link rel="shortcut icon" href="images/favicon.ico" type="image/x-icon">
    <link rel="icon" href="images/favicon.ico" type="image/x-icon">
    
    <meta http-equiv="X-UA-Compatible" content="IE=edge">
    <meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0">
    <link href="css/responsive.css" rel="stylesheet">

.default-form textarea {
        height: 44px;
        resize: none;
    }

.formButton {
        padding: 2px 20px;
        background-color: #3D9CE2;
        cursor: pointer;
        display: inline-block;
        margin-right: 5px;
    }
</style>

<header class="main-header header-style-one">

<?php include ('menu.php');?> 
        </header>

<section class="page-title" style="background-image:url(images/background/page-title-1.jpg);">
            <div class="auto-container">
                <div class="row clearfix">
                    
                    <div class="title-column col-md-6 col-sm-12 col-xs-12">
                        <h1>Enquiry</h1>
                    </div>
                    
                    <div class="breadcrumb-column col-md-6 col-sm-12 col-xs-12">
                        <ul class="bread-crumb clearfix">
                            <li><a href="index.php">Home</a></li>
                            <li><a href="#">Pages</a></li>
                            <li class="active">Contact Us</li>
                        </ul>
                    </div>
                </div>
            </div>
        </section>

<section class="contact-section sec-pdd-85-90">
            <div class="auto-container">
                <div class="row clearfix">
                    
                    <div class="col-sm-8 ">
                        <div class="default-title">
                            <h3>ENQUIRY</h3>
                        </div>

<div class="contact-form default-form">
                            <form action="https://www.replservices.com/TestResult_attach_captcha_code.php" method="post" name="Enquiry" onSubmit="return onSubmit()" enctype ="multipart/form-data">
                                <input name="redirect" type="hidden">
                                <input name="recipient" type="hidden"
                                    value="response@replservices.com, websupport1@mipl.co.in">
                                <input name="subject" type="hidden" value="Enquiry From Website">
                                <div class="LeftForm">
                                    <input maxLength="100" name="CompanyName" size="30" class="inputField"
                                        placeholder="Name of Company :" tabindex="1">
                                    <input maxLength="100" name="contact_person" size="30" class="inputField"
                                        placeholder="Name of Contact Person *:" tabindex="2">
                                    <input maxLength="100" name="telNo" size="18" class="inputField"
                                        placeholder="Tel. No. / Cell No. *:" tabindex="3">
                                    <input maxLength="100" name="from" size="29" class="inputField"
                                        placeholder="Email *:" tabindex="4">
                                </div>
                                <div class="RightForm">
                                    <textarea cols="34" name="Address" rows="3" MAXLENGTH="100" class="inputField"
                                        placeholder="Address / City / Location :" tabindex="5"></textarea>
                                    <select name="country" id="country" class="inputField" style="color: gray;">
                                        <option value="" selected>Select a country</option>
                                        <option value="India">India</option>
                                        <option value="Other">Other</option>
                                        <option value="Afghanistan">Afghanistan</option>
                                        <option value="Albania">Albania</option>
                                        <option value="Algeria">Algeria</option>
                                        <option value="American Samoa">American Samoa</option>
                                        <option value="Andorra">Andorra</option>
                                        <option value="Angola">Angola</option>
                                        <option value="Anguilla">Anguilla</option>
                                        <option value="Antarctica">Antarctica</option>
                                        <option value="Antigua and Barbuda">Antigua and Barbuda</option>
                                        <option value="Argentina">Argentina</option>
                                        <option value="Armenia">Armenia</option>
                                        <option value="Aruba">Aruba</option>
                                        <option value="Australia">Australia</option>
                                        <option value="Austria">Austria</option>
                                        <option value="Azerbaijan">Azerbaijan</option>
                                        <option value="Bahamas">Bahamas</option>
                                        <option value="Bahrain">Bahrain</option>
                                        <option value="Bangladesh">Bangladesh</option>
                                        <option value="Barbados">Barbados</option>
                                        <option value="Belarus">Belarus</option>
                                        <option value="Belgium">Belgium</option>
                                        <option value="Belize">Belize</option>
                                        <option value="Benin">Benin</option>
                                        <option value="Bermuda">Bermuda</option>
                                        <option value="Bhutan">Bhutan</option>
                                        <option value="Bolivia">Bolivia</option>
                                        <option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option>
                                        <option value="Botswana">Botswana</option>
                                        <option value="Bouvet Island">Bouvet Island</option>
                                        <option value="Brazil">Brazil</option>
                                        <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
                                        <option value="Brunei Darussalam">Brunei Darussalam</option>
                                        <option value="Bulgaria">Bulgaria</option>
                                        <option value="Burkina Faso">Burkina Faso</option>
                                        <option value="Burundi">Burundi</option>
                                        <option value="Cambodia">Cambodia</option>
                                        <option value="Cameroon">Cameroon</option>
                                        <option value="Canada">Canada</option>
                                        <option value="Cape Verde">Cape Verde</option>
                                        <option value="Cayman Islands">Cayman Islands</option>
                                        <option value="Central African Republic">Central African Republic</option>
                                        <option value="Chad">Chad</option>
                                        <option value="Chile">Chile</option>
                                        <option value="China">China</option>
                                        <option value="Christmas Island">Christmas Island</option>
                                        <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
                                        <option value="Colombia">Colombia</option>
                                        <option value="Comoros">Comoros</option>
                                        <option value="Congo">Congo</option>
                                        <option value="Congo, the Democratic Republic of the">Congo, the Democratic Republic of the</option>
                                        <option value="Cook Islands">Cook Islands</option>
                                        <option value="Costa Rica">Costa Rica</option>
                                        <option value="Cote d'Ivoire">Cote d'Ivoire</option>
                                        <option value="Croatia (Hrvatska)">Croatia (Hrvatska)</option>
                                        <option value="Cuba">Cuba</option>
                                        <option value="Cyprus">Cyprus</option>
                                        <option value="Czech Republic">Czech Republic</option>
                                        <option value="Denmark">Denmark</option>
                                        <option value="Djibouti">Djibouti</option>
                                        <option value="Dominica">Dominica</option>
                                        <option value="Dominican Republic">Dominican Republic</option>
                                        <option value="East Timor">East Timor</option>
                                        <option value="Ecuador">Ecuador</option>
                                        <option value="Egypt">Egypt</option>
                                        <option value="El Salvador">El Salvador</option>
                                        <option value="Equatorial Guinea">Equatorial Guinea</option>
                                        <option value="Eritrea">Eritrea</option>
                                        <option value="Estonia">Estonia</option>
                                        <option value="Ethiopia">Ethiopia</option>
                                        <option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
                                        <option value="Faroe Islands">Faroe Islands</option>
                                        <option value="Fiji">Fiji</option>
                                        <option value="Finland">Finland</option>
                                        <option value="France">France</option>
                                        <option value="France, Metropolitan">France, Metropolitan</option>
                                        <option value="French Guiana">French Guiana</option>
                                        <option value="French Polynesia">French Polynesia</option>
                                        <option value="French Southern Territories">French Southern Territories</option>
                                        <option value="Gabon">Gabon</option>
                                        <option value="Gambia">Gambia</option>
                                        <option value="Georgia">Georgia</option>
                                        <option value="Germany">Germany</option>
                                        <option value="Ghana">Ghana</option>
                                        <option value="Gibraltar">Gibraltar</option>
                                        <option value="Greece">Greece</option>
                                        <option value="Greenland">Greenland</option>
                                        <option value="Grenada">Grenada</option>
                                        <option value="Guadeloupe">Guadeloupe</option>
                                        <option value="Guam">Guam</option>
                                        <option value="Guatemala">Guatemala</option>
                                        <option value="Guinea">Guinea</option>
                                        <option value="Guinea-Bissau">Guinea-Bissau</option>
                                        <option value="Guyana">Guyana</option>
                                        <option value="Haiti">Haiti</option>
                                        <option value="Heard and Mc Donald Islands">Heard and Mc Donald Islands</option>
                                        <option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
                                        <option value="Honduras">Honduras</option>
                                        <option value="Hong Kong">Hong Kong</option>
                                        <option value="Hungary">Hungary</option>
                                        <option value="Iceland">Iceland</option>
                                        <option value="India">India</option>
                                        <option value="Indonesia">Indonesia</option>
                                        <option value="Iran (Islamic Republic of)">Iran (Islamic Republic of)</option>
                                        <option value="Iraq">Iraq</option>
                                        <option value="Ireland">Ireland</option>
                                        <option value="Israel">Israel</option>
                                        <option value="Italy">Italy</option>
                                        <option value="Jamaica">Jamaica</option>
                                        <option value="Japan">Japan</option>
                                        <option value="Jordan">Jordan</option>
                                        <option value="Kazakhstan">Kazakhstan</option>
                                        <option value="Kenya">Kenya</option>
                                        <option value="Kiribati">Kiribati</option>
                                        <option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
                                        <option value="Korea, Republic of">Korea, Republic of</option>
                                        <option value="Kuwait">Kuwait</option>
                                        <option value="Kyrgyzstan">Kyrgyzstan</option>
                                        <option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
                                        <option value="Latvia">Latvia</option>
                                        <option value="Lebanon">Lebanon</option>
                                        <option value="Lesotho">Lesotho</option>
                                        <option value="Liberia">Liberia</option>
                                        <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
                                        <option value="Liechtenstein">Liechtenstein</option>
                                        <option value="Lithuania">Lithuania</option>
                                        <option value="Luxembourg">Luxembourg</option>
                                        <option value="Macau">Macau</option>
                                        <option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</option>
                                        <option value="Madagascar">Madagascar</option>
                                        <option value="Malawi">Malawi</option>
                                        <option value="Malaysia">Malaysia</option>
                                        <option value="Maldives">Maldives</option>
                                        <option value="Mali">Mali</option>
                                        <option value="Malta">Malta</option>
                                        <option value="Marshall Islands">Marshall Islands</option>
                                        <option value="Martinique">Martinique</option>
                                        <option value="Mauritania">Mauritania</option>
                                        <option value="Mauritius">Mauritius</option>
                                        <option value="Mayotte">Mayotte</option>
                                        <option value="Mexico">Mexico</option>
                                        <option value="Micronesia, Federated States of">Micronesia, Federated States of</option>
                                        <option value="Moldova, Republic of">Moldova, Republic of</option>
                                        <option value="Monaco">Monaco</option>
                                        <option value="Mongolia">Mongolia</option>
                                        <option value="Montserrat">Montserrat</option>
                                        <option value="Morocco">Morocco</option>
                                        <option value="Mozambique">Mozambique</option>
                                        <option value="Myanmar">Myanmar</option>
                                        <option value="Namibia">Namibia</option>
                                        <option value="Nauru">Nauru</option>
                                        <option value="Nepal">Nepal</option>
                                        <option value="Netherlands">Netherlands</option>
                                        <option value="Netherlands Antilles">Netherlands Antilles</option>
                                        <option value="New Caledonia">New Caledonia</option>
                                        <option value="New Zealand">New Zealand</option>
                                        <option value="Nicaragua">Nicaragua</option>
                                        <option value="Niger">Niger</option>
                                        <option value="Nigeria">Nigeria</option>
                                        <option value="Niue">Niue</option>
                                        <option value="Norfolk Island">Norfolk Island</option>
                                        <option value="Northern Mariana Islands">Northern Mariana Islands</option>
                                        <option value="Norway">Norway</option>
                                        <option value="Oman">Oman</option>
                                        <option value="Pakistan">Pakistan</option>
                                        <option value="Palau">Palau</option>
                                        <option value="Panama">Panama</option>
                                        <option value="Papua New Guinea">Papua New Guinea</option>
                                        <option value="Paraguay">Paraguay</option>
                                        <option value="Peru">Peru</option>
                                        <option value="Philippines">Philippines</option>
                                        <option value="Pitcairn">Pitcairn</option>
                                        <option value="Poland">Poland</option>
                                        <option value="Portugal">Portugal</option>
                                        <option value="Puerto Rico">Puerto Rico</option>
                                        <option value="Qatar">Qatar</option>
                                        <option value="Reunion">Reunion</option>
                                        <option value="Romania">Romania</option>
                                        <option value="Russia">Russia</option>
                                        <option value="Rwanda">Rwanda</option>
                                        <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> 
                                        <option value="Saint LUCIA">Saint LUCIA</option>
                                        <option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
                                        <option value="Samoa">Samoa</option>
                                        <option value="San Marino">San Marino</option>
                                        <option value="Sao Tome and Principe">Sao Tome and Principe</option> 
                                        <option value="Saudi Arabia">Saudi Arabia</option>
                                        <option value="Senegal">Senegal</option>
                                        <option value="Seychelles">Seychelles</option>
                                        <option value="Sierra Leone">Sierra Leone</option>
                                        <option value="Singapore">Singapore</option>
                                        <option value="Slovakia (Slovak Republic)">Slovakia (Slovak Republic)</option>
                                        <option value="Slovenia">Slovenia</option>
                                        <option value="Solomon Islands">Solomon Islands</option>
                                        <option value="Somalia">Somalia</option>
                                        <option value="South Africa">South Africa</option>
                                        <option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
                                        <option value="Spain">Spain</option>
                                        <option value="Sri Lanka">Sri Lanka</option>
                                        <option value="St. Helena">St. Helena</option>
                                        <option value="St. Pierre and Miquelon">St. Pierre and Miquelon</option>
                                        <option value="Sudan">Sudan</option>
                                        <option value="Suriname">Suriname</option>
                                        <option value="Svalbard and Jan Mayen Islands">Svalbard and Jan Mayen Islands</option>
                                        <option value="Swaziland">Swaziland</option>
                                        <option value="Sweden">Sweden</option>
                                        <option value="Switzerland">Switzerland</option>
                                        <option value="Syrian Arab Republic">Syrian Arab Republic</option>
                                        <option value="Taiwan, Province of China">Taiwan, Province of China</option>
                                        <option value="Tajikistan">Tajikistan</option>
                                        <option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
                                        <option value="Thailand">Thailand</option>
                                        <option value="Togo">Togo</option>
                                        <option value="Tokelau">Tokelau</option>
                                        <option value="Tonga">Tonga</option>
                                        <option value="Trinidad and Tobago">Trinidad and Tobago</option>
                                        <option value="Tunisia">Tunisia</option>
                                        <option value="Turkey">Turkey</option>
                                        <option value="Turkmenistan">Turkmenistan</option>
                                        <option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
                                        <option value="Tuvalu">Tuvalu</option>
                                        <option value="Uganda">Uganda</option>
                                        <option value="Ukraine">Ukraine</option>
                                        <option value="United Arab Emirates">United Arab Emirates</option>
                                        <option value="United Kingdom">United Kingdom</option>
                                        <option value="United States">United States</option>
                                        <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
                                        <option value="Uruguay">Uruguay</option>
                                        <option value="Uzbekistan">Uzbekistan</option>
                                        <option value="Vanuatu">Vanuatu</option>
                                        <option value="Venezuela">Venezuela</option>
                                        <option value="Viet Nam">Viet Nam</option>
                                        <option value="Virgin Islands (British)">Virgin Islands (British)</option>
                                        <option value="Virgin Islands (U.S.)">Virgin Islands (U.S.)</option>
                                        <option value="Wallis and Futuna Islands">Wallis and Futuna Islands</option>
                                        <option value="Western Sahara">Western Sahara</option>
                                        <option value="Yemen">Yemen</option>
                                        <option value="Yugoslavia">Yugoslavia</option>
                                        <option value="Zambia">Zambia</option>
                                        <option value="Zimbabwe">Zimbabwe</option>
                                    </select>
                                    <textarea cols="34" placeholder="Quantity of Products *:" name="quantity_details"
                                        rows="3" MAXLENGTH="100" class="inputField" tabindex="6"></textarea>
                                    <textarea cols="34" placeholder="Requirements Details *:" name="requirement_details"
                                        rows="3" MAXLENGTH="5000" class="inputField" tabindex="6"></textarea>
                                     <div class="form-group has-feedback mt-3">
                <label>Please Enter Verification Code in the box : <span>*</span></label>
                <img id="output" src="data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAEgAAAAZAQMAAACo8fpWAAAABlBMVEUAAAD///+l2Z/dAAAAYElEQVQImWNgoDbgZzj/4cAHHiBLsvGA4cMZMkCWweEDxsY8NiDWsQNpkjNyQLJnDhyT+HAGyOK7cbBNcmYPSPP9x2zSvP+ADIEDx5iNecCmNJxhfDiDB2zyGQaIydQAAHT5HkMzHV/jAAAAAElFTkSuQmCC" /> 
<input type="hidden" name="random_key" value="9788a007-767f-448b-bdc9-8f07bb6d2429" id="random_key">
<input type="hidden" name="domain_name" value="www.replservices.com" id="domain_name">
                    <input type="text" name="q" class="form-control input">
                    
                <div class="dt-sc-margin10"></div>
            </div>
                                   
                                    <div class="buttonWrapper">
                                        <input type="submit" value="Submit" class="formButton" style="color: #fff;">
                                        <input type="reset" value="Reset" class="formButton" style="color:#fff;">
                                    </div>
                                </div>
                                <div class="clear"></div>
                            </form>

</div>
                    </div>

<div class="col-md-3 col-md-offset-1 " style="background-color: #eaeaea;">
                        <?php include ('service-menu.php');?> 
                    </div>

</div>
            </div>
        </section>

<footer class="main-footer" style="background-image:url(images/background/animation-image-2.png);">
     <?php include ('footer.php');?>  
    </footer>

</div>

<div class="scroll-to-top scroll-to-target" data-target=".main-header"><span
            class="icon fa fa-long-arrow-up"></span></div>

$(window).load(function () {
            modal.style.display = "block";
        });

</html>

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