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danine1

form-gewinnspiel

Nov 15th, 2018
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HTML 5 2.32 KB | None | 0 0
  1. <div id="form-gewinnspiel">
  2. <div class="form-instructions">
  3.     <p>Mach mit und gewinne einen E-Roller! Einfach das Formular ausfüllen und die Zukunft von E-Mobility selber ausprobieren.</p>
  4. </div>
  5. <div class="panel">
  6. <div class="acl-contest-response-window alert" style="display: none;">
  7. <div class="alert--content"></div>
  8. </div>
  9. <form method="post" action="{url controller=aclcontest action=addnewentry}" class="acl-contest-form">
  10. <div class="panel--body is--wide form-gewinn">
  11. <div class="namefields">
  12. <div class="form-gewinn-firstname">
  13. Vorname:*<br>
  14. <input type="text" name="firstname" required /><br>
  15. </div>
  16. <div class="form-gewinn-lastname">
  17. Nachname:*<br>
  18. <input type="text" name="lastname" required /><br>
  19. </div>
  20. </div>
  21. <div class="streetfields">
  22. <div class="form-gewinn-street">
  23. Straße:*<br>
  24. <input type="text" name="street" required /><br>
  25. </div>
  26. <div class="form-gewinn-plz">
  27. PLZ*<br>
  28. <input type="text" name="zipcode" required /><br>
  29. </div>
  30. </div>
  31. <div class="areafields">
  32. <div class="form-gewinn-city">
  33. Ort*<br>
  34. <input type="text"  name="city" required /><br>
  35. </div>
  36. <div class="form-gewinn-email">
  37. E-mail*<br>
  38. <input type="email"  name="email" required /><br>
  39. </div>
  40. </div>
  41. <div class="contactfields">
  42. <div class="form-gewinn-phone">
  43. Telefonnummer<br>
  44. <input type="text" name="phone"><br>
  45. </div>
  46. <div class="form-gewinn-birthday">
  47. Geburtsdatum* (e.g. 28.10.2001)<br>
  48. <input type="text" name="birthdate" required><br>
  49. </div>
  50. </div>
  51. <div class="form-gewinn-datenshutz">
  52. <input type="checkbox" required name="agreement">
  53. Ich akzeptiere die <a href="https://shop.wienenergie.at/datenschutz" target="_blank">Datenschutzerklärung.</a><br>
  54. <input type="checkbox" required name="conditions">
  55. Ich akzeptiere die <a href="https://shop.wienenergie.at/media/pdf/84/e3/1d/05092018_Teilnahmebedingungen_Gewinnspiel.pdf" target="_blank">Teilnahmebedingungen.</a><br><br>
  56. </div>
  57. <button type="submit" class="btn btn-info button-gewinn-submit">Jetzt gewinnen</button>
  58. <div class="tickets-image-gewinn">
  59. <img src="https://shop.wienenergie.at/media/image/f7/14/8f/180917_WEN_Stadt-Wien_Websitebild_510x510_E-Roller5b9fbd28626e7.png" alt="ticket">
  60. <a href="https://shop.wienenergie.at/media/pdf/a8/cd/08/NIU_N1S_C1-C3_N1S-EU4_GER.pdf" target="_blank">Zur Produktbeschreibung</a><br>
  61. </div>
  62. </div>
  63. </div>
  64. </form>
  65. </div>
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