
<?php  include 'includes/header.php'; ?>

<style>
    .logoimg img {
    max-width: 120px !important;
    margin: 0 auto;
    display: table;
}
.reserve_form {
    padding: 0 0;
}
.allYourSec h1 {
    color: #f69a16;
    text-transform: capitalize;
}
.btn_submit .btn-default {
    color: #fff;
    background-color: #f69a16;
    border-color: #f69a16;
    font-size: 16px;
    padding: 6px 20px;
    transition: all .3s ease-in-out;
}
</style>


	<section class="girl_rbg">
        <div class="employment_form">
            <div class="container">
                <div class="reserve_form">
                    <div class="row">
                        <div class="col-md-12">
                            <div class="allYourSec">
                                <h1>PUBLISHING Questionnaire</h1>

                               
                            </div>
                        </div>
                    </div>
                    <!-- Form Start -->
                    <form action="sendmail.php" id="web-form" class="form form-get-quote" method="POST" enctype="multipart/form-data">
                      <input type="hidden" name="form_id" value="59183">
                        <div class="row">
                            <div class="col-md-12">
                                <div class="panel-group" id="accordion">
                                    <div class="panel panel-default">
                                        <div class="col-md-12">
                                            <div class="panel-heading">
                                                <h4 class="panel-title">
                                                    Publishing Details Required</h4><br>
                                            </div>
                                        </div>
                                       
                                        <div id="collapse1" class="panel-collapse collapse in">
                                            <div class="panel-body">
                                            <div class="row">
                                                    <div class="col-md-6">
                                                        <div class="form-group">
                                                            <label>OFFICIAL AUTHOR NAME<p class="text-danger">*</p></label>
                                                            <input type="text" name="quote[company_author_name]" class="form-control"
                                                                   placeholder=""
                                                                   onkeydown="return /^[A-Za-z\s]+$/.test(event.key)" required>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-6">
                                                        <div class="form-group">
                                                            <label>OFFICIAL BOOK NAME <p class="text-danger">*</p></label>
                                                            <input type="text" name="quote[company_book_name]" class="form-control"
                                                                   placeholder=""
                                                                   required>
                                                        </div>
                                                    </div>
                                                </div>
                                               
                                               <div class="row">
                                                   <div class="col-md-12">
                                                        <div class="form-group">
                                                             <label>Official Author Description: (About the Author) <p class="text-danger">*</p></label>
                                                            <textarea name="quote[company_description]" class="form-control" placeholder="" rows="10" data-error="Type your message..." aria-required="true"></textarea>
                                                        </div>
                                                   </div>
                                               </div>
                                                <div class="row">
                                                   <div class="col-md-12">
                                                        <div class="form-group">
                                                             <label>Product Description: (About the Book) <p class="text-danger">*</p></label>
                                                            <textarea name="quote[company_product_description]" class="form-control" placeholder="" rows="10" data-error="Type your message..." aria-required="true"></textarea>
                                                        </div>
                                                   </div>
                                               </div>
                                                <div class="row">
                                                 <div class="col-md-12">
                                                        <div class="form-group">
                                                            <label>ISBN (With Imprint): <p class="text-danger">*</p></label>
                                                            <input type="text" name="quote[company_isbn]" class="form-control"
                                                                   placeholder=""
                                                                   >
                                                        </div>
                                                    </div>
                                                    </div>
                                                    <div class="row">
                                                    <div class="col-md-12">
                                                        <div class="form-group">
                                                            <label>KEYWORDS: <p class="text-danger">*</p></label>
                                                            <input type="text" name="quote[company_keywords]" class="form-control"
                                                                   placeholder=""
                                                                   >
                                                        </div>
                                                    </div>
                                                    </div>
                                                         <div class="row">
                                                    <div class="col-md-12">
                                                        <div class="form-group">
                                                            <label>GENRE: <p class="text-danger">*</p></label>
                                                            <input type="text" name="quote[company_genre]" class="form-control"
                                                                   placeholder=""
                                                                   >
                                                        </div>
                                                    </div>
                                                    </div>
                                               
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="panel panel-default mt-5">
                                    <div class="panel-heading">
                                   <h4 class="panel-title">
                                        Personal Details</h4>
                                        </div>
                                        <br>
                                    <div id="collapse2" class="panel-collapse collapse in">
                                        <div class="panel-body">
                                          
                                            <div class="row">
                                                <div class="col-md-12">
                                                    <h4>Email Address <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="email" name="quote[company_email]" class="form-control"
                                                           placeholder=""
                                                           required>
                                                </div>
                                                
                                                <div class="col-md-12">
                                                    <h4>Password: <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_Password]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                                 <div class="col-md-12">
                                                    <h4>Complete Name: <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_name]" class="form-control"
                                                           placeholder=""
                                                           required>
                                                </div>
                                                <div class="col-md-12">
                                                    <h4>Complete Address (No Abbreviations): <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                   <input type="text" name="quote[company_address]" class="form-control"
                                                           placeholder=""
                                                           required>
                                                </div>
                                                  <div class="col-md-12">
                                                    <h4>Active Phone Number: <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="tel" name="quote[company_phone]" class="form-control"
                                                           placeholder=""
                                                           required>
                                                </div>
                                              
                                            
                                           
                                              
                                               
                                            
        
                                            </div>
                                            
                                          
                                        </div>
                                    </div>
                                </div>
                                
                                
                                 <div class="panel panel-default mt-5">
                                    <div class="panel-heading">
                                   <h4 class="panel-title">
                                        Account Details (In order to receive Royalties)</h4>
                                        </div>
                                        <br>
                                    <div id="collapse2" class="panel-collapse collapse in">
                                        <div class="panel-body">
                                          
                                            <div class="row">
                                                <div class="col-md-12">
                                                    <h4>Social Security Number: <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_security_number]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                                
                                                <div class="col-md-12">
                                                    <h4>Bank Account Holder Name (Exact name as mentioned in the bank):   <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <textarea name="quote[company_account]" class="form-control" placeholder="" rows="10" data-error="Type your message..." aria-required="true"></textarea>
                                                </div>
                                                 <div class="col-md-12">
                                                    <h4>Account type Checking or Savings): <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_type]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                                <div class="col-md-12">
                                                    <h4>Account Number:  <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                   <input type="text" name="quote[company_account_number]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                                  <div class="col-md-12">
                                                    <h4>Routing Number: <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_routing]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                              
                                               <div class="col-md-12">
                                                    <h4>Name Of Bank <span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_bank_name]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                              
                                                 <div class="col-md-12">
                                                    <h4>Full Name (As shown in the tax return)<span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input type="text" name="quote[company_full_name]" class="form-control"
                                                           placeholder=""
                                                           >
                                                </div>
                                               
                                              <div class="col-md-12">
                                                    <h4>Click Here to Upload File<span class="text-danger">*</span></h4>
                                                </div>
                                                <div class="col-md-12">
                                                    <input class="form-control" type="file" name="image[]" multiple value="" />
                                                </div>
        
                                            </div>
                                            <br>
                                            <div class="row">
													<div class="col-md-12">
														<div class="btn_submit text-center">
															<button class="btn btn-default" type="submit">Submit
															</button>
														</div>
													</div>
												</div>
                                        </div>
                                    </div>
                                </div>
                             
                            </div>
                        </div>
                    </form>
                    <!-- Form End -->
                </div>
            </div>
        </div>
    </section>
  








<?php  include 'includes/footer.php'; ?>