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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Document</title>
<script src="https://cdn.jsdelivr.net/npm/jquery@3.7.0/dist/jquery.min.js"
integrity="sha256-2Pmvv0kuTBOenSvLm6bvfBSSHrUJ+3A7x6P5Ebd07/g=" crossorigin="anonymous"></script>
<script src="https://cdn.jsdelivr.net/npm/fomantic-ui@2.9.2/dist/semantic.min.js"
integrity="sha256-k89McqiQeAeH3zwEUu8tOiKsHSYgZ4cvxaYhPtPOg34=" crossorigin="anonymous"></script>
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/fomantic-ui@2.9.2/dist/semantic.min.css"
integrity="sha256-ot9Eohfi9t3iQkCNQKYTu9O9kjKx5iJ5hkQ0u1xZLik=" crossorigin="anonymous">
</head>
<body>
<div class="ui container">
<form class="ui form">
<h4 class="ui dividing header">Instant Quote</h4>
<div class="field">
<label>Name</label>
<div class="two fields">
<div class="field">
<input type="text" name="shipping[first-name]" placeholder="First Name">
</div>
<div class="field">
<input type="text" name="shipping[last-name]" placeholder="Last Name">
</div>
</div>
</div>
<div class="field">
<label>Service Address</label>
<div class="fields">
<div class="twelve wide field">
<input type="text" name="shipping[address]" placeholder="Street Address">
</div>
<div class="four wide field">
<input type="text" name="shipping[address-2]" placeholder="Apt #">
</div>
</div>
</div>
<div class="two fields">
<div class="ten wide field">
<label>State</label>
<select class="ui fluid dropdown">
<option value="">State</option>
<option value="ACT">Australian Capital Territory</option>
<option value="NSW">New South Wales</option>
<option value="NT">Northern Territory</option>
<option value="QLD">Queensland</option>
<option value="SA">South Australia</option>
<option value="TAS">Tasmania</option>
<option value="VIC" selected="selected">Victoria</option>
<option value="WA">Western Australia</option>
</select>
</div>
<div class="six wide field">
<label>Postcode</label>
<input type="text" name="shipping[postcode]" placeholder="3000">
</div>
</div>
<h4 class="ui dividing header">Usage information</h4>
<div class="ui cards">
<label>What kind of calls do you handle?</label><br><br>
<div class="ui card">
<div class="image">
<i class="massive angle double down icon"></i>
</div>
<div class="content">
<a class="header">Receieve</a>
<div class="description">
We mostly receieve calls, with few outbound calls
</div>
</div>
</div>
<div class="ui card">
<div class="image">
<i class="massive balance scale icon"></i>
</div>
<div class="content">
<a class="header">Balanced</a>
<div class="description">
We have a good balance of inbound and outbound calls
</div>
</div>
</div>
<div class="ui card">
<div class="image">
<i class="massive angle double up icon"></i>
</div>
<div class="content">
<a class="header">Make</a>
<div class="description">
We mostly make outbound calls
</div>
</div>
</div>
</div>
<br><br>
<div class="ui cards">
<div class="ui card">
<div class="image">
<i class="massive headset icon"></i>
</div>
<div class="content">
<a class="header">Receieve</a>
<div class="description">
We mostly receieve calls, with few outbound calls
</div>
</div>
</div>
<div class="ui card">
<div class="image">
<i class="massive balance scale icon"></i>
</div>
<div class="content">
<a class="header">Balanced</a>
<div class="description">
We have a good balance of inbound and outbound calls
</div>
</div>
</div>
<div class="ui card">
<div class="image">
<i class="massive angle double up icon"></i>
</div>
<div class="content">
<a class="header">Make</a>
<div class="description">
We mostly make outbound calls
</div>
</div>
</div>
</div>
<br><br>
<div class="field">
<label>How many staff do you have?</label>
<div class="ui labeled ticked slider" id="interpretedlabel"></div>
<script>
var labels = ['1', '2', '3', '4', '5', '6', '7', '8', '9', '10+'];
$('#interpretedlabel')
.slider({
min: 1, max: 10,
interpretLabel: function (value) {
return labels[value];
}
})
;
</script>
</div>
<div class="fields">
<div class="seven wide field">
<label>Card Number</label>
<input type="text" name="card[number]" maxlength="16" placeholder="Card #">
</div>
<div class="three wide field">
<label>CVC</label>
<input type="text" name="card[cvc]" maxlength="3" placeholder="CVC">
</div>
<div class="six wide field">
<label>Expiration</label>
<div class="fields">
<div class="eight wide field">
<select class="ui fluid search dropdown" name="card[expire-month]">
<option value="">Month</option>
<option value="1">January</option>
<option value="2">February</option>
<option value="3">March</option>
<option value="4">April</option>
<option value="5">May</option>
<option value="6">June</option>
<option value="7">July</option>
<option value="8">August</option>
<option value="9">September</option>
<option value="10">October</option>
<option value="11">November</option>
<option value="12">December</option>
</select>
</div>
<div class="field">
<input type="text" name="card[expire-year]" maxlength="4" placeholder="Year">
</div>
</div>
</div>
</div>
<h4 class="ui dividing header">Receipt</h4>
<div class="field">
<label>Send Receipt To:</label>
<div class="ui fluid multiple search selection dropdown">
<input type="hidden" name="receipt">
<i class="dropdown icon"></i>
<div class="default text">Saved Contacts</div>
<div class="menu">
<div class="item" data-value="jenny" data-text="Jenny">
<img class="ui mini avatar image" src="/images/avatar/small/jenny.jpg">
Jenny Hess
</div>
<div class="item" data-value="elliot" data-text="Elliot">
<img class="ui mini avatar image" src="/images/avatar/small/elliot.jpg">
Elliot Fu
</div>
<div class="item" data-value="stevie" data-text="Stevie">
<img class="ui mini avatar image" src="/images/avatar/small/stevie.jpg">
Stevie Feliciano
</div>
<div class="item" data-value="christian" data-text="Christian">
<img class="ui mini avatar image" src="/images/avatar/small/christian.jpg">
Christian
</div>
<div class="item" data-value="matt" data-text="Matt">
<img class="ui mini avatar image" src="/images/avatar/small/matt.jpg">
Matt
</div>
<div class="item" data-value="justen" data-text="Justen">
<img class="ui mini avatar image" src="/images/avatar/small/justen.jpg">
Justen Kitsune
</div>
</div>
</div>
</div>
<div class="ui segment">
<div class="field">
<div class="ui toggle checkbox">
<input type="checkbox" name="gift" tabindex="0" class="hidden">
<label>Do not include a receipt in the package</label>
</div>
</div>
</div>
<div class="ui button" tabindex="0">Submit Order</div>
</form>
</div>
</body>
</html>