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Jul 4th, 2015
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  1. <form class="form-horizontal" enctype="multipart/form-data" action="./validation/invia.php" method="POST">
  2. <input type="hidden" name="destinatario" value="antonio.junior98@libero.it" />
  3. <fieldset>
  4.  
  5. <!-- Form Name -->
  6.  
  7.  
  8. <legend>Informazioni auto <h6>Completa con i dati della tua auto</h6></legend>
  9.  
  10. <!-- Text input-->
  11. <div class="form-group">
  12.   <label class="col-md-3 control-label" for="textinput">Marca</label>  
  13.   <div class="col-md-3">
  14.     <input id="textinput" name="marca" type="text" placeholder="Marca" class="form-control input-md" required>
  15.   </div>
  16.  
  17.  
  18. <!-- Multiple Radios (inline) -->
  19.  
  20.   <label class="col-md-3 control-label" for="textimput">Modello</label>
  21.   <div class="col-md-3">
  22.    <input id="textinput" name="modello" type="text" placeholder="Modello" class="form-control input-md" required>
  23.   </div>
  24. </div>
  25.  
  26.  
  27. <div class="form-group">
  28.   <label class="col-md-3 control-label" for="textinput">Immatricolazione</label>  
  29.   <div class="col-md-3">
  30.     <input id="textinput" name="immatricolazione" type="text" placeholder="Immatricolazione" class="form-control input-md" required>
  31.   </div>
  32.   <label class="col-md-3 control-label" for="textinput">Carburante</label>  
  33.   <div class="col-md-3">
  34.     <input id="textinput" name="carburante" type="text" placeholder="Carburante" class="form-control input-md" required>
  35.   </div>
  36.  </div>
  37.  
  38.  
  39.  <div class="form-group">
  40.   <label class="col-md-3 control-label" for="textinput">Cilindrata</label>  
  41.   <div class="col-md-3">
  42.     <input id="textinput" name="cilindrata" type="text" placeholder="Cilindrata" class="form-control input-md" required>
  43.   </div>
  44.   <label class="col-md-3 control-label" for="textinput">Nr. di Targa</label>  
  45.   <div class="col-md-3">
  46.     <input id="textinput" name="nditarga" type="text" placeholder="Nr. di Targa" class="form-control input-md" required>
  47.   </div>
  48.  </div>
  49.  
  50.  
  51.  
  52.  <legend>Informazioni Sinistro <h6>Aggiungi maggiori informazioni riguardanti il Sinistro</h6></legend>
  53.  
  54. <div class="form-group">
  55.   <label class="col-md-3 control-label" for="textarea">Altre info sul Sinistro</label>
  56.   <div class="col-md-9">                    
  57.     <textarea class="form-control" id="textarea" name="infosinistro" required></textarea>
  58.     <label class="col-md-8 control-label" for="textinput">Carica le foto del sinistro</label>
  59.         <input name="allegato" type="file">
  60.   </div>
  61. </div>
  62.  
  63.  
  64. <legend>Dati Personali  <h6>Inserisci i tuoi dati personali o intestatario del veicolo</h6> </legend>
  65.  <div class="form-group">
  66.   <label class="col-md-3 control-label" for="textinput">Nome</label>  
  67.   <div class="col-md-3">
  68.     <input id="textinput" name="nome" type="text" placeholder="Nome" class="form-control input-md" required>
  69.   </div>
  70.   <label class="col-md-3 control-label" for="textinput">Cognome</label>  
  71.   <div class="col-md-3">
  72.     <input id="textinput" name="cognome" type="text" placeholder="Cognome" class="form-control input-md" required>
  73.   </div>
  74.  </div>
  75.  
  76.  
  77.  <div class="form-group">
  78.   <label class="col-md-3 control-label" for="textinput">Telefono</label>  
  79.   <div class="col-md-3">
  80.     <input id="textinput" name="telefono" type="text" placeholder="Telefono" class="form-control input-md" required>
  81.   </div>
  82.   <label class="col-md-3 control-label" for="textinput">E-mail</label>  
  83.   <div class="col-md-3">
  84.     <input id="textinput" name="email" type="text" placeholder="E-mail" class="form-control input-md" required>
  85.   </div>
  86.  </div>
  87.  
  88. <div class="form-group">
  89.   <div class="col-md-12">
  90.   <center> <input type="checkbox" name="datipers" value="Il cliente autorizza il trattamento dei dati personali, ai sensi del D.lgs. 196 del 30 giugno 2003." required /> Autorizzo il trattamento dei miei dati personali, ai sensi del D.lgs. 196 del 30 giugno 2003  <br>
  91.    <input type="checkbox" name="newsletter" value="Il cliente si iscrive alla newsletter."/> Voglio iscrivermi alla newsletter e ricevere periodicamente nuove promozioni  
  92.   </center>
  93.   </div>
  94. </div>
  95.  
  96. <div class="form-group">
  97.   <label class="col-md-3 control-label" for="textarea"></label>
  98.   <div class="col-md-9">                      
  99.   </div>
  100. </div>
  101.  
  102.  
  103. <div class="form-group">
  104.   <label class="col-md-3 control-label" for="button1id"></label>
  105.   <div class="col-md-8">          
  106.     <button id="button1id" type="submit" name="submit" value="invia" class="btn btn-success">INVIA</button>
  107.   </div>
  108. </div>
  109.  
  110. </fieldset>
  111. </form>
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