<form action="/inquiries" class="new_inquiry form" id="new_inquiry" method="post"><div style="margin:0;padding:0;display:inline"><input name="authenticity_token" type="hidden" value="TLOxUEiWoPIA8elVWpOFkGvUa2f9AJUlJmeRQcYS9gc=" /></div>
<ol>
<li>
<ol>
<li class='field'>
<label class="required" for="inquiry_name">Naam *</label>
<input id="inquiry_name" name="inquiry[name]" size="30" type="text" />
</li>
<li class='field'>
<label class="required" for="inquiry_title">Titel *</label>
<select id="inquiry_title" name="inquiry[title]"><option value="Dhr.">Dhr.</option>
<option value="Mevr.">Mevr.</option></select>
</li>
</ol>
</li>
<li>
<ol>
<li class='field'>
<label class="required" for="inquiry_postalcode">Postcode *</label>
<input id="inquiry_postalcode" name="inquiry[postalcode]" size="30" type="text" />
</li>
<li class='field'>
<label class="required" for="inquiry_city">Plaats *</label>
<input id="inquiry_city" name="inquiry[city]" size="30" type="text" />
</li>
</ol>
</li>
<li class='field'>
<label class="required" for="inquiry_street">Straat en huisnummer *</label>
<input id="inquiry_street" name="inquiry[street]" size="30" type="text" />
</li>
<li>
<ol>
<li class='field'>
<label class="required" for="inquiry_phone">Telefoon *</label>
<input id="inquiry_phone" name="inquiry[phone]" size="30" type="text" />
</li>
<li class='field'>
<label for="inquiry_email">Email</label>
<input id="inquiry_email" name="inquiry[email]" size="30" type="text" />
</li>
</ol>
</li>
<li class='field message_field'>
<label for="inquiry_message">Opmerkingen</label>
<textarea cols="40" id="inquiry_message" name="inquiry[message]" rows="8">Ik zou graag door DieetPlaneet worden teruggebeld om een afspraak te maken.</textarea>
</li>
</ol>
<div class='actions'>
<input id="inquiry_submit" name="commit" type="submit" value="Versturen" />
</div>
</form>