seyitaslan / web-reqeust.github.io Goto Github PK

<form form="https://app.modaltrans.com/roster/web_request_quotes" method="post">
  <!-- Form elements -->
</form>

<script src="https://app.modaltrans.com/roster/web_requests/cdn.js"></script>

<input type="hidden" id="patron_token" name="web_request_quote[patron_token]" value="{{YOUR_ACCOUNT_TOKEN}}" required>

<input type="hidden" id="redirect_url" name="web_request_quote[redirect_url]" value="{{YOUR_REDIRECT_URL}}" required>

<label for="name">Name</label>
<input type="text" id="name" name="web_request_quote[name]" required>

<label for="company_name">Company Name</label>
<input type="text" id="company_name" name="web_request_quote[company_name]" required>

<label for="tax_no">Tax No</label>
<input type="text" id="tax_no" name="web_request_quote[tax_no]">

<label for="email">Email</label>
<input type="text" id="email" name="web_request_quote[email]" required>

<label for="phone">Phone</label>
<input type="text" id="phone" name="web_request_quote[phone]">

<label for="trans_mode">Transport Mode</label>
<select id="trans_mode" name="web_request_quote[datas][trans_mode]" required>
  <option value="road">Road</option>
  <option value="sea">Sea</option>
  <option value="air">Air</option>
  <option value="rail">Rail</option>
</select>

<label for="full_partial">Shipment Type</label>
<select id="full_partial" name="web_request_quote[datas][full_partial]" required>
  <option value="partial">Partial</option>
  <option value="full">Full</option>
</select>

<label for="total_package">Total Package</label>
<input type="number" id="total_package" name="web_request_quote[datas][total_package]">

<label for="gross_weight">Gross Weight</label>
<input type="number" id="gross_weight" name="web_request_quote[datas][gross_weight]">

<label for="total_volume">Total Volume</label>
<input type="number" id="total_volume" name="web_request_quote[datas][total_volume]">

<label for="lead_class">Lead Class</label>
<select id="lead_class" name="web_request_quote[datas][lead_class]" required>
    <option value="standard">Standard</option>
    <option value="adr">ADR</option>
    <option value="perishable">Perishable</option>
    <option value="pharma">Pharma</option>
    <option value="animal">Animal</option>
    <option value="funeral">Funeral</option>
    <option value="other_special_cargo">Other Special Cargo</option>
    <option value="bulk">Bulk</option>
</select>

<label for="origin_address">Origin Address</label>
<input type="text" id="origin_address" name="web_request_quote[datas][origin_address]" required>

<label for="origin_postcode">Origin Postcode</label>
<input type="text" id="origin_postcode" name="web_request_quote[datas][origin_postcode]">

<label for="origin_country_id">Origin Country</label>
<select id="origin_country_id" name="web_request_quote[datas][origin_country_id]" mdl-web-request="countries_option" required>
  <option value=""></option>
</select>

<label for="destination_address">Destination Address</label>
<input type="text" id="destination_address" name="web_request_quote[datas][destination_address]" required>

<label for="destination_postcode">Destination Postcode</label>
<input type="text" id="destination_postcode" name="web_request_quote[datas][destination_postcode]">

<label for="destination_country_id">Destination Country</label>
<select id="destination_country_id" name="web_request_quote[datas][destination_country_id]" mdl-web-request="countries_option" required>
  <option value=""></option>
</select>

<label for="special_instructions">Special Instructions</label>
<textarea id="special_instructions" name="web_request_quote[datas][special_instructions]"></textarea>

<label for="customer_ref">Customer Reference</label>
<input type="text" id="customer_ref" name="web_request_quote[datas][customer_ref]">

<label for="notes">Notes</label>
<textarea id="notes" name="web_request_quote[datas][notes]"></textarea>

<div mdl-web-request="recaptcha"></div>