Kriuchko
1/8/2019 - 1:50 PM
Form custom form форма с html и стилями
Wordpress form with html and css
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
<title>InspectionMeasurementCompany</title>
<link media="all" rel="stylesheet" type="text/css" href="css/all.css" />
<script type="text/javascript" src="js/jquery-1.8.3.min.js"></script>
<script type="text/javascript" src="js/jquery.main.js"></script>
</head>
<body>
<div id="wrapper">
<?php
require_once('class.phpmailer.php');
if(isset($_REQUEST['date']))
{
$date = $_REQUEST['date'];
$account = $_REQUEST['account'];
$soldinfo = $_REQUEST['sold-info'];
$shipinfo = $_REQUEST['ship-info'];
$company = $_REQUEST['company'];
$address = $_REQUEST['address'];
$dateby = $_REQUEST['date-by'];
$po = $_REQUEST['p-o'];
$shipvia = $_REQUEST['ship-via'];
$attn = $_REQUEST['attn'];
$phone = $_REQUEST['phone'];
$email = $_REQUEST['email'];
$partprod01 = $_REQUEST['part-prod-01'];
$quantity01 = $_REQUEST['quantity-01'];
$descr01 = $_REQUEST['descr-01'];
$price01 = $_REQUEST['price-01'];
$partprod02 = $_REQUEST['part-prod-02'];
$quantity02 = $_REQUEST['quantity-02'];
$descr02 = $_REQUEST['descr-02'];
$price02 = $_REQUEST['price-02'];
$partprod03 = $_REQUEST['part-prod-03'];
$quantity03 = $_REQUEST['quantity-03'];
$descr03 = $_REQUEST['descr-03'];
$price03 = $_REQUEST['price-03'];
$partprod04 = $_REQUEST['part-prod-04'];
$quantity04 = $_REQUEST['quantity-04'];
$descr04 = $_REQUEST['descr-04'];
$price04 = $_REQUEST['price-04'];
$partprod05 = $_REQUEST['part-prod-05'];
$quantity05 = $_REQUEST['quantity-05'];
$descr05 = $_REQUEST['descr-05'];
$price05 = $_REQUEST['price-05'];
$partprod06 = $_REQUEST['part-prod-06'];
$quantity06 = $_REQUEST['quantity-06'];
$descr06 = $_REQUEST['descr-06'];
$price06 = $_REQUEST['price-06'];
$partprod07 = $_REQUEST['part-prod-07'];
$quantity07 = $_REQUEST['quantity-07'];
$descr07 = $_REQUEST['descr-07'];
$price07 = $_REQUEST['price-07'];
$partprod08 = $_REQUEST['part-prod-08'];
$quantity08 = $_REQUEST['quantity-08'];
$descr08 = $_REQUEST['descr-08'];
$price08 = $_REQUEST['price-08'];
$cusmomerreview = $_REQUEST['cusmomer-review'];
$semiannually = $_REQUEST['semi-annually'];
if(!empty($semiannually)){
$semiannuallychecked = 'checked="checked"';
}
$annually = $_REQUEST['annually'];
if(!empty($annually)){
$annuallychecked = 'checked="checked"';
}
$other = $_REQUEST['other'];
if(!empty($other)){
$otherchecked = 'checked="checked"';
}
$ifyou = $_REQUEST['if-you'];
if(!empty($ifyou)){
$ifyouchecked = 'checked="checked"';
}
$date02 = $_REQUEST['date-02'];
$forimc = $_REQUEST['for-imc'];
$ifacceptable = $_REQUEST['if-acceptable'];
if(!empty($ifacceptable)){
$ifacceptablechecked = 'checked="checked"';
}
$ifnotacceptable = $_REQUEST['if-notacceptable'];
if(!empty($ifnotacceptable)){
$ifnotacceptablechecked = 'checked="checked"';
}
$customercontact = $_REQUEST['customer-contact'];
$date03 = $_REQUEST['date-03'];
$mail = new PHPMailer();
$mail->IsHTML(true);
$mail->Body = '
<div class="request-form validate-form">
<fieldset>
<div class="info-box">
<h2>SALES ORDER REQUEST</h2>
<div class="holder">
<div class="col">
<div class="row">
<label for="val01">Date:</label>
<input name="date" type="text" id="val01" value="'.$date.'" class="required-number" />
</div>
<div class="row">
<label for="val02">Account #:</label>
<input name="account" type="text" value="'.$account.'" id="val02" class="required-number"/>
</div>
<div class="row">
<label for="val03">Sold To:</label>
<textarea name="sold-info" class="required" id="val03" cols="30" rows="10">'.$soldinfo.'</textarea>
</div>
<div class="row row-alt">
<label for="val04">Ship Via:</label>
<input name="ship-via" value="'.$shipvia.'" type="text" id="val04" class="required-number"/>
</div>
<div class="row">
<label for="val05">Company:</label>
<input name="company" value="'.$company.'" type="text" id="val05" class="required"/>
</div>
<div class="row">
<label for="val06">Co. Address:</label>
<input name="address" value="'.$address.'" type="text" id="val06" class="required" />
</div>
</div>
<div class="col">
<div class="row">
<label for="val07">By:</label>
<input name="date-by" value="'.$dateby.'" type="text" id="val07" class="required-number" />
</div>
<div class="row">
<label for="val08">P.O. #:</label>
<input name="p-o" value="'.$po.'" type="text" id="val08" class="required-number" />
</div>
<div class="row">
<label for="val09">Ship To:</label>
<textarea name="ship-info" class="required" id="val09" cols="30" rows="10">'.$shipinfo.'</textarea>
</div>
<div class="row row-alt">
<label for="val10">Attn:</label>
<input name="attn" value="'.$attn.'" type="text" id="val10" class="required"/>
</div>
<div class="row">
<label for="val11">Contact Phone #:</label>
<input name="phone" value="'.$phone.'" type="text" id="val11" class="required-number"/>
</div>
<div class="row">
<label for="val12">Contact Email: </label>
<input name="email" value="'.$email.'" type="text" id="val12" class="required-email"/>
</div>
</div>
</div>
<span class="receive-text">(You will receive a receipt of this order form to this address)</span>
</div>
<div class="products-box">
<div class="row">
<div class="col01">
<strong class="title">PART / PROD #</strong>
</div>
<div class="col01 col02">
<strong class="title">QUANTITY</strong>
</div>
<div class="col01 col03">
<strong class="title">DESCRIPTION</strong>
</div>
<div class="col01 col04">
<strong class="title">PRICE</strong>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-01" value="'.$partprod01.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-01" type="text" value="'.$quantity01.'" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-01" type="text" value="'.$descr01.'" class="required"/>
</div>
<div class="col01 col04">
<input name="price-01" type="text" value="'.$price01.'" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-02" value="'.$partprod02.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-02" value="'.$quantity02.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-02" value="'.$descr02.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-02" value="'.$price02.'" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-03" value="'.$partprod03.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-03" value="'.$quantity03.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-03" value="'.$descr03.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-03" value="'.$price03.'" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-04" value="'.$partprod04.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-04" value="'.$quantity04.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-04" value="'.$descr04.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-04" value="'.$price04.'" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-05" value="'.$partprod05.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-05" value="'.$quantity05.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-05" value="'.$descr05.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-05" value="'.$price05.'" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-06" value="'.$partprod06.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-06" value="'.$quantity06.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-06" value="'.$descr06.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-06" value="'.$price06.'" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-07" value="'.$partprod07.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-07" value="'.$quantity07.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-07" value="'.$descr07.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-07" value="'.$price07.'" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-08" value="'.$partprod08.'" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-08" value="'.$quantity08.'" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-08" value="'.$descr08.'" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-08" value="'.$price08.'" type="text" class="required-number"/>
</div>
</div>
</div>
<div class="contact-box">
<div class="order-box">
<h2>CUSTOMER CONTRACT REVIEW</h2>
<p>In regards to your purchase order <input type="text" name="cusmomer-review" value="'.$cusmomerreview.'" class="required-number"/>, ISO 17025 requires that you give us the interval for recalibration of your gauges.</p>
</div>
<div class="mark-box">
<h3>Please Mark:</h3>
<div class="row">
<div class="box">
<label for="option01">Semi-Annually:</label>
<input type="checkbox" '.$semiannuallychecked.' name="option" id="option01" />
</div>
<span class="text">( Instrument is used weekly- experiences minimal adjustment )</span>
</div>
<div class="row">
<div class="box">
<label for="option02">Annually:</label>
<input type="checkbox" '.$annuallychecked.' name="option" id="option02" />
</div>
<span class="text">( Customer experiences minimal to no adjustments of the instrument )</span>
</div>
<div class="row">
<div class="box">
<label for="option03">Other: </label>
<input type="checkbox" '.$otherchecked.' name="option" id="option03" />
</div>
<span class="text">( Customer uses check standards and instrument has no adjustment for several cycles )</span>
</div>
<div class="row">
<div class="box01">
<label for="option04">If you would like this interval for all purchase orders please check here:</label>
<input type="checkbox" '.$ifyouchecked.' name="option" id="option04" />
</div>
<div class="box02">
<label for="val13">Date:</label>
<input type="text" id="val13" value="'.$date02.'" name="date-02" class="required-number"/>
</div>
</div>
</div>
<div class="procedure-box">
<h3>Procedure Acceptance</h3>
<p>IMC will use internal calibration procedures CIMC-1 thru CIMC-32, including measurement uncertainties, which are part of IMC\'s quality system, unless the customer specifies the following procedure:</p>
<div class="row"><input type="text" value="'.$forimc.'" class="required"/><span class="text">for IMC to follow.</span></div>
</div>
<div class="calibration-box">
<h3>Outsourced Calibration</h3>
<p>IMC will only outsource calibration for which we are not currently accredited.</p>
<p>Customer approves IMC to outsource calibration to an accredited laboratory, A2LA mutually recognizes.</p>
<div class="row">
<label for="option05">If the above is acceptable, please check here:</label>
<input type="checkbox" '.$ifacceptablechecked.' name="option02" id="option05" />
</div>
<div class="row">
<label for="option06">If the above is NOT acceptable, please check here: </label>
<input type="checkbox" '.$ifnotacceptablechecked.' name="option02" id="option06" />
</div>
<div class="row">
<div class="box">
<label for="val14">Customer Contact:</label>
<input type="text" value="'.$customercontact.'" id="val14" class="required-number"/>
</div>
<div class="box">
<label for="val15">Date:</label>
<input type="text" value="'.$date03.'" id="val15" name="date-03" class="required-number"/>
</div>
</div>
</div>
</div>
</fieldset>
</div>
<style type="text/css">
body {
margin:0;
color:#000;
font:12px/17px Arial, Helvetica, sans-serif;
background: #fff;
min-width:1000px;
}
img {border-style:none;}
a {
text-decoration:underline;
color:#000;
}
a:hover {text-decoration:none;}
a:active {background-color: transparent;}
input,
textarea,
select {
font:100% Arial, Helvetica, sans-serif;
vertical-align:middle;
color:#000;
}
form, fieldset {
margin:0;
padding:0;
border-style:none;
}
#wrapper{
width:658px;
margin:0 auto;
}
.request-form{
padding:18px 28px 20px 20px;
}
.request-form h2{
font-size:20px;
line-height:21px;
text-transform:uppercase;
color:#080b80;
border-bottom:1px solid #000;
margin:0 21px 31px 0;
}
.request-form .row:after{
content:"";
display:block;
clear:both;
}
.info-box{
position:relative;
padding:0 0 26px;
margin:0 0 25px;
}
.info-box:after{
content:"";
position:absolute;
left:9px;
right:12px;
bottom:0;
height:10px;
background:#ccc;
}
.info-box .holder{overflow:hidden;}
.info-box .col{
float:left;
width:300px;
}
.info-box .col:first-child{
margin:0 18px 0 0;
width:260px;
}
.info-box .row{margin:0 0 13px;}
.info-box .row-alt{margin:0 0 31px;}
.info-box label{
text-align:right;
float:left;
margin:-2px 16px 0 0;
width:95px;
}
.info-box .col:first-child label{
width:77px;
margin:-2px 13px 0 0;
}
.request-form input[type="text"]{
float:left;
font-size:10px;
line-height:12px;
height:15px;
padding:3px 5px;
width:157px;
border:1px solid #ccc;
}
.request-form .error input[type="text"],
.request-form .error textarea{
border:1px solid #ff0000;
color:#ff0000;
}
.request-form textarea{
float:left;
border:1px solid #ccc;
padding:5px;
width:157px;
min-width:157px;
max-width:157px;
height:64px;
min-height:64px;
overflow:auto;
margin:0;
}
.info-box .receive-text{
display:block;
text-align:right;
margin:-3px 14px 0;
}
.products-box{
overflow:hidden;
position:relative;
padding:0 0 18px 9px;
margin:0 0 22px;
}
.products-box:after{
content:"";
position:absolute;
left:9px;
right:12px;
bottom:0;
height:10px;
background:#ccc;
}
.products-box .title{
text-transform:uppercase;
display:block;
padding:0 0 0 12px;
}
.products-box .col01{
float:left;
width:129px;
margin:0 17px 0 0;
}
.products-box .row{
margin:0 0 16px;
overflow:hidden;
}
.products-box .row:first-child{margin:0 0 11px;}
.products-box .col01 input[type="text"]{
width:117px;
margin:0;
}
.products-box .col02{
width:76px;
margin:0 32px 0 0;
}
.products-box .col02 input[type="text"]{width:64px;}
.products-box .col03{
width:198px;
margin:0 20px 0 0;
}
.products-box .col03 input[type="text"]{width:186px;}
.products-box .col04{
width:107px;
margin:0;
}
.products-box .col04 input[type="text"]{width:95px;}
.order-box{padding:0 20px 0 0;}
.order-box input[type="text"]{
display:inline-block;
float:none;
width:60px;
margin:-3px 4px -2px;
}
.order-box h2{margin:0 0 23px;}
.order-box p{margin:0 0 15px;}
.contact-box h3{
font-size:15px;
line-height:17px;
margin:0 0 18px;
}
.request-form input[type="checkbox"]{
width:17px;
height:16px;
float:left;
margin:1px 0 0;
}
.mark-box{padding:0 0 11px;}
.mark-box .row{margin:0 0 17px;}
.mark-box .row:after{
content:"";
display:block;
clear:both;
}
.mark-box label{
width:99px;
float:left;
}
.mark-box .box{
width:125px;
float:left;
margin:0 20px 0 0;
}
.mark-box .text{
float:left;
word-spacing:-1px;
margin:0 -5px 0 0;
}
.row .box01{
margin:0 34px 0 0;
float:left;
}
.row .box01 label{
width:auto;
margin:0 5px 0 0;
}
.row .box02{float:left;}
.row .box02 label{
margin:0 5px 0 0;
width:auto;
}
.row .box02 input[type="text"]{
width:78px;
margin:-1px 0 0;
}
.procedure-box{padding:0 0 15px;}
.procedure-box p{margin:0 0 12px;}
.procedure-box input[type="text"]{
display:inline-block;
width:299px;
margin:0 12px 0 2px;
}
.procedure-box .row .text{
padding:5px 0 0;
float:left;
}
.calibration-box{padding:0 0 11px;}
.calibration-box p{margin:0 0 17px;}
.calibration-box .row{margin:0 0 17px;}
.calibration-box label{
width:278px;
margin:0 5px 0 0;
float:left;
}
.calibration-box input[type="checkbox"]{float:left;}
.calibration-box .box{
float:left;
padding:15px 11px 0 0;
}
.calibration-box .box label{
width:auto;
padding:2px 0 0;
}
.calibration-box .box:first-child input[type="text"]{width:197px;}
.calibration-box .box input[type="text"]{width:90px;}
.btns-box{
overflow:hidden;
padding:0 6px;
}
.request-form input[type="reset"]{
width:47px;
height:19px;
font-size:11px;
line-height:13px;
margin:0 0 0 17px;
background: url(../images/btn-reset.png) no-repeat;
border-style:none;
float:right;
padding:0 0 2px;
cursor:pointer;
}
.request-form input[type="submit"]{
width:86px;
height:19px;
font-size:11px;
line-height:13px;
margin:0 0 0 17px;
background: url(../images/btn-submit.png) no-repeat;
border-style:none;
float:right;
padding:0 0 2px;
letter-spacing:1px;
cursor:pointer;
}
</style>
';
$mail->AltBody .= 'Date: '.$date."\n";
$mail->AltBody .= 'Account #: '.$account."\n";
$mail->AltBody .= 'Sold To: '.$soldinfo."\n";
$mail->AltBody .= 'Ship Via: '.$shipvia."\n";
$mail->AltBody .= 'Co. Address: '.$address."\n";
$mail->AltBody .= 'By: '.$dateby."\n";
$mail->AltBody .= 'P.O. #: '.$po."\n";
$mail->AltBody .= 'Ship To: '.$shipinfo."\n";
$mail->AltBody .= 'Attn: '.$attn."\n";
$mail->AltBody .= 'Contact Phone #: '.$phone."\n";
$mail->AltBody .= 'Contact Email: '.$email."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod01."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity01."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr01."\n";
$mail->AltBody .= 'PRICE: '.$price01."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod02."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity02."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr02."\n";
$mail->AltBody .= 'PRICE: '.$price02."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod03."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity03."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr03."\n";
$mail->AltBody .= 'PRICE: '.$price03."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod04."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity04."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr04."\n";
$mail->AltBody .= 'PRICE: '.$price04."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod05."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity05."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr05."\n";
$mail->AltBody .= 'PRICE: '.$price05."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod06."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity06."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr06."\n";
$mail->AltBody .= 'PRICE: '.$price06."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod07."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity07."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr07."\n";
$mail->AltBody .= 'PRICE: '.$price07."\n";
$mail->AltBody .= 'PART / PROD #:'.$partprod08."\n";
$mail->AltBody .= 'QUANTITY: '.$quantity08."\n";
$mail->AltBody .= 'DESCRIPTION: '.$descr08."\n";
$mail->AltBody .= 'PRICE: '.$price08."\n";
$mail->AltBody .= 'In regards to your purchase order: '.$cusmomerreview."\n";
$mail->AltBody .= 'Semi-Annually: '.$semiannually."\n";
$mail->AltBody .= 'Annually: '.$annually."\n";
$mail->AltBody .= 'If you would like this interval for all purchase orders please check here: '.$ifyou."\n";
$mail->AltBody .= 'Date: '.$date02."\n";
$mail->AltBody .= 'IMC will use internal calibration procedures CIMC-1 thru CIMC-32, including measurement uncertainties, which are part of IMC\'s quality system, unless the customer specifies the following procedure: '.$forimc."\n";
$mail->AltBody .= 'If the above is acceptable, please check here: '.$ifacceptable."\n";
$mail->AltBody .= 'If the above is NOT acceptable, please check here: '.$ifnotacceptable."\n";
$mail->AltBody .= 'Customer Contact: '.$customercontact."\n";
$mail->AltBody .= 'Date: '.$date03."\n";
$mail->SetFrom($email, $name);
$mail->AddReplyTo($email, $account);
$mail->AddAddress('test@gmail.com', "Inspection Measurement Company");
if(!empty($email))
{
$mail->AddAddress($email, "Inspection Measurement Company");
}
$mail->Subject = "Inspection Measurement Company";
if(!$mail->Send()) {
echo "<div class=\"form-error\">Mailer Error: " . $mail->ErrorInfo."</div>";
}
}
?>
<form action="" name="sales-contract-form" class="request-form validate-form" method="post">
<fieldset>
<div class="info-box">
<h2>SALES ORDER REQUEST</h2>
<div class="holder">
<div class="col">
<div class="row">
<label for="val01">Date:</label>
<input name="date" type="text" id="val01" class="required-number" />
</div>
<div class="row">
<label for="val02">Account #:</label>
<input name="account" type="text" id="val02" class="required-number"/>
</div>
<div class="row">
<label for="val03">Sold To:</label>
<textarea name="sold-info" class="required" id="val03" cols="30" rows="10"></textarea>
</div>
<div class="row row-alt">
<label for="val04">Ship Via:</label>
<input name="ship-via" type="text" id="val04" class="required-number"/>
</div>
<div class="row">
<label for="val05">Company:</label>
<input name="company" type="text" id="val05" class="required"/>
</div>
<div class="row">
<label for="val06">Co. Address:</label>
<input name="address" type="text" id="val06" class="required" />
</div>
</div>
<div class="col">
<div class="row">
<label for="val07">By:</label>
<input name="date-by" type="text" id="val07" class="required-number" />
</div>
<div class="row">
<label for="val08">P.O. #:</label>
<input name="p-o" type="text" id="val08" class="required-number" />
</div>
<div class="row">
<label for="val09">Ship To:</label>
<textarea name="ship-info" class="required" id="val09" cols="30" rows="10"></textarea>
</div>
<div class="row row-alt">
<label for="val10">Attn:</label>
<input name="attn" type="text" id="val10" class="required"/>
</div>
<div class="row">
<label for="val11">Contact Phone #:</label>
<input name="phone" type="text" id="val11" class="required-number"/>
</div>
<div class="row">
<label for="val12">Contact Email: </label>
<input name="email" type="text" id="val12" class="required-email"/>
</div>
</div>
</div>
<span class="receive-text">(You will receive a receipt of this order form to this address)</span>
</div>
<div class="products-box">
<div class="row">
<div class="col01">
<strong class="title">PART / PROD #</strong>
</div>
<div class="col01 col02">
<strong class="title">QUANTITY</strong>
</div>
<div class="col01 col03">
<strong class="title">DESCRIPTION</strong>
</div>
<div class="col01 col04">
<strong class="title">PRICE</strong>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-01" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-01" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-01" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-01" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-02" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-02" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-02" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-02" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-03" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-03" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-03" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-03" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-04" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-04" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-04" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-04" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-05" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-05" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-05" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-05" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-06" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-06" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-06" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-06" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-07" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-07" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-07" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-07" type="text" class="required-number"/>
</div>
</div>
<div class="row">
<div class="col01">
<input name="part-prod-08" type="text" class="required-number" />
</div>
<div class="col01 col02">
<input name="quantity-08" type="text" class="required-number"/>
</div>
<div class="col01 col03">
<input name="descr-08" type="text" class="required"/>
</div>
<div class="col01 col04">
<input name="price-08" type="text" class="required-number"/>
</div>
</div>
</div>
<div class="contact-box">
<div class="order-box">
<h2>CUSTOMER CONTRACT REVIEW</h2>
<p>In regards to your purchase order <input type="text" name="cusmomer-review" class="required-number"/>, ISO 17025 requires that you give us the interval for recalibration of your gauges.</p>
</div>
<div class="mark-box">
<h3>Please Mark:</h3>
<div class="row">
<div class="box">
<label for="option01">Semi-Annually:</label>
<input type="checkbox" name="semi-annually" id="option01" />
</div>
<span class="text">( Instrument is used weekly- experiences minimal adjustment )</span>
</div>
<div class="row">
<div class="box">
<label for="option02">Annually:</label>
<input type="checkbox" name="annually" id="option02" />
</div>
<span class="text">( Customer experiences minimal to no adjustments of the instrument )</span>
</div>
<div class="row">
<div class="box">
<label for="option03">Other: </label>
<input type="checkbox" name="other" id="option03" />
</div>
<span class="text">( Customer uses check standards and instrument has no adjustment for several cycles )</span>
</div>
<div class="row">
<div class="box01">
<label for="option04">If you would like this interval for all purchase orders please check here:</label>
<input type="checkbox" name="if-you" id="option04" />
</div>
<div class="box02">
<label for="val13">Date:</label>
<input type="text" id="val13" name="date-02" class="required-number"/>
</div>
</div>
</div>
<div class="procedure-box">
<h3>Procedure Acceptance</h3>
<p>IMC will use internal calibration procedures CIMC-1 thru CIMC-32, including measurement uncertainties, which are part of IMC's quality system, unless the customer specifies the following procedure:</p>
<div class="row"><input type="text" name="for-imc" class="required"/><span class="text">for IMC to follow.</span></div>
</div>
<div class="calibration-box">
<h3>Outsourced Calibration</h3>
<p>IMC will only outsource calibration for which we are not currently accredited.</p>
<p>Customer approves IMC to outsource calibration to an accredited laboratory, A2LA mutually recognizes.</p>
<div class="row">
<label for="option05">If the above is acceptable, please check here:</label>
<input type="checkbox" name="if-acceptable" id="option05" />
</div>
<div class="row">
<label for="option06">If the above is NOT acceptable, please check here: </label>
<input type="checkbox" name="if-notacceptable" id="option06" />
</div>
<div class="row">
<div class="box">
<label for="val14">Customer Contact:</label>
<input type="text" id="val14" name="customer-contact" class="required-number"/>
</div>
<div class="box">
<label for="val15">Date:</label>
<input type="text" id="val15" name="date-03" class="required-number"/>
</div>
</div>
</div>
</div>
<div class="btns-box">
<input type="reset" value="Reset" />
<input type="submit" value="Submit Form" />
</div>
</fieldset>
</form>
</div>
</body>
</html>