File: /home/commandorestoration/public_html/contact.php
<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<meta name="description" content="">
<meta name="author" content="Stephen Mayers">
<meta name="generator" content="Hugo 0.84.0">
<title>Commando Restoration</title>
<link href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-T3c6CoIi6uLrA9TneNEoa7RxnatzjcDSCmG1MXxSR1GAsXEV/Dwwykc2MPK8M2HN" crossorigin="anonymous">
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.1/jquery.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/jquery.validate.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery.mask/1.14.15/jquery.mask.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-ui-timepicker-addon/1.6.3/jquery-ui-timepicker-addon.min.js"></script>
<script src="dobpicker.js"></script>
<!-- Bootstrap core CSS -->
<link href="../assets/dist/css/bootstrap.min.css" rel="stylesheet">
<style>
.bd-placeholder-img {
font-size: 1.125rem;
text-anchor: middle;
-webkit-user-select: none;
-moz-user-select: none;
user-select: none;
}
@media (min-width: 768px) {
.bd-placeholder-img-lg {
font-size: 3.5rem;
}
}
</style>
<!-- Custom styles for this template -->
<link href="starter-template.css" rel="stylesheet">
</head>
<body>
<div class="col-lg-8 mx-auto p-3 py-md-5">
<div class="container">
<header class="d-flex flex-wrap justify-content-center py-3 mb-4 border-bottom">
<a href="/" class="d-flex align-items-center mb-3 mb-md-0 me-md-auto text-dark text-decoration-none">
<img width="100%" height="123" src="https://commandorestoration.com/wp-content/uploads/2022/06/cropped-Commando-Logo-Black-new-2048x1500.png" class="attachment-large size-large wp-image-34" alt="">
</a>
<ul class="nav nav-pills d-flex align-items-center">
<li class="nav-item"><a href="Tel: +18883102912" class="nav-link active" aria-current="page" style="background: #FC9E00; border: 0px; color: #000000; font-size: 22px; font-weight: 600;"> +1 (888) 310-2912 </a></li>
</ul>
</header>
</div>
<main>
<h1 class="text-center">Contact Us</h1>
<div class="row g-5 mt-2">
<form id="valForm" name="valForm" class="valForm" method="get" class="p-4">
<input type="hidden" name="xxTrustedFormCertUrl" id="xxTrustedFormCertUrl_0" value="https://cert.trustedform.com/454a35b802f3e7b63ffabb4efedb7c6ebe67886c">
<input type="hidden" name="DateOfBirth" id="dob">
<input type="hidden" name="CompanyId" id="CompanyId" value="16">
<div class="row">
<h3 class="display-6 mb-3 text-center"> Who are we speaking to?</h3>
<div class="col-md-6">
<div class="form-floating mb-4">
<input id="firstname" type="text" name="firstname" class="firstname form-control alpha required" placeholder="First Name" required>
<label for="firstname d-flex justify-content-center">First Name *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your First Name. </div>
</div>
</div>
<!-- /column -->
<div class="col-md-6">
<div class="form-floating mb-4">
<input id="lastname" type="text" name="lastname" class="lastname form-control alpha" placeholder="Last Name" required>
<label for="lastname d-flex justify-content-center">Last Name *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your Last Name. </div>
</div>
</div>
<div class="col-md-6">
<div class="form-floating mb-4">
<input type="text" class="form-control phone numer" name="phone" id="phone" placeholder="Phone Number" minlength="10" maxlength="10" maxlength="30" required>
<label for="phone">Phone Number *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your Phone Number. </div>
</div>
</div>
<!-- /column -->
<div class="col-md-6">
<div class="form-floating mb-4">
<input id="email" type="text" name="email" class="email form-control" placeholder="Email Address" required>
<label for="email">Email *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your Email Address. </div>
</div>
</div>
<section>
</section>
<!--Step 5 -->
<section class="wrapper bg-gradient-primary mb-1">
<h2 class="display-6 mb-3 text-center"> What is your current address?</h2>
<div class="row formStepper-p-0">
<div class="col-md-12">
<div class="form-floating mb-4">
<input id="address" type="text" name="address" class="address form-control" placeholder="Street Address" required>
<label for="address" class="he-form-field">Street Address *</label>
</div>
</div>
<div class="col-md-4">
<div class="form-floating mb-4">
<input type="text" class="form-control numer zipCode" minlength="5" maxlength="5" name="zip" id="zipCode" placeholder="Zip Code" onkeyup="zipCodeLookup(1);" value="<?php echo $_POST["zipCode"]; ?>">
<label for="zipcode">Zip Code *</label>
</div>
</div>
<!-- /column -->
<div class="col-md-4">
<div class="form-floating mb-4">
<input type="text" class="form-control numer city" name="city" id="city" placeholder="City" value="<?php echo $_POST["city"]; ?>" required>
<label for="city">City *</label>
</div>
</div>
<div class="col-md-4">
<div class="form-floating mb-4">
<input type="text" class="form-control numer state" name="state" id="state" placeholder="State" value="<?php echo $_POST["state"]; ?>" required>
<label for="state">State *</label>
</div>
</div>
<input value="Submit" id="submitButton" sid="datepicker" class="btn btn-primary btn-lg px-4" style="background: #FC9E00; border: 0px; color:#000000; font-weight: 600;" type="submit">
</form>
</div>
</div>
<footer class="footer-area" style="padding-bottom: 20px;">
<div class="copyright-area">
<!-- copyright area -->
<div class="container">
<div class="row">
<div class="col-lg-12">
<div class="copyright-inner">
<!-- copyright inner wrapper -->
<div class="text-center">
<!-- left content area -->
© Commando Restoration 2024 | All Rights Reserved. <a href="https://commandorestoration.com/privacy">Privacy Policy</a>
</div>
<!-- //. left content aera -->
</div>
<!-- //.copyright inner wrapper -->
</div>
</div>
</div>
</div>
<!-- //. copyright area -->
</footer>
<!-- footer area end -->
<!-- back to top area start -->
<div class="back-to-top">
<i class="fas fa-angle-up"></i>
</div>
<!-- back to top area end -->
<!-- TrustedForm -->
<script type="text/javascript">
(function() {
var tf = document.createElement('script');
tf.type = 'text/javascript'; tf.async = true;
tf.src = ("https:" == document.location.protocol ? 'https' : 'http') + "://api.trustedform.com/trustedform.js?field=xxTrustedFormCertUrl&identifier=VHQ&ping_field=xxTrustedFormPingUrl&l=" + new Date().getTime() + Math.random();
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(tf, s);
})();
</script>
<noscript>
<img src="https://api.trustedform.com/ns.gif" />
</noscript>
<!-- End TrustedForm -->
<script>
function submitForm()
{
$('#submitButton').prop('disabled', true);
$.ajax({
type: 'post',
dataType:'jsonp',
url: 'https://ushaleads.healthinsuranceguide.org/api/LeadAPI',
data: $('form').serialize(),
success: function () {
console.log('success');
window.location.href = "form-success.php";
},
error:function(){
console.log('Error');
window.location.href = "form-success.php";
}
})
};
$(document).ready(function(){
$('input:checkbox').click(function() {
$('input:checkbox').not(this).prop('checked', false);
});
});
/*-----------------------------------------------------------------------*/
/*----------------------- Phone Number Input Mask -----------------------*/
/*-----------------------------------------------------------------------*/
$(document).ready(function(){
$('#phone').mask('0000000000');
});
/*-----------------------------------------------------------------------*/
/*---------------------------- Zip Code Lookup --------------------------*/
/*-----------------------------------------------------------------------*/
$('#zipCode').on("input",function(){
var zipCode = $('#zipCode').val();
if(zipCode.length == 5)
{
$.ajax({
type: 'GET',
url:'https://ziplookup.visualyzers.com/Ziplookup?zipcode=' + zipCode,
success:function(results){
$('#city').val(results.city);
$('#state').val(results.state);
}
})
}
});
/*-------------------------------------------------------------------------*/
/*---------------------------- Validation Lookup --------------------------*/
/*-------------------------------------------------------------------------*/
$("#valForm").submit(function(e) {
e.preventDefault();
}).validate({
rules:{
phone:{
required:true,
minlength:10,
maxlength:10
},
firstname:{
required:true
},
lastname:{
required:true
},
dateofbirth:{
required:true,
date:true,
},
typeofplan:{
required: true
},
email:{
required:true,
email:true
},
city:{
required:true
},
state:{
required:true
},
zipCode:{
required:true,
minlength:5,
maxlength:5
}
},
messages: {
phone: {
required: "Please enter a valid phone number"
},
},
submitHandler: function(event)
{
submitForm();
}
});
$(function() {
$( "#datepicker" ).datepicker({
dateFormat : 'mm/dd/yy',
changeMonth : true,
changeYear : true,
yearRange: '-100y:c+nn',
maxDate: '-1d'
});
});
</script>
<script>
/*-----------------------------------------------------------------------*/
/*--------------------------- Date of Birth ----------------------------*/
/*-----------------------------------------------------------------------*/
$(document).ready(function() {
$.getJSON('https://api.ipify.org?format=jsonp&callback=?', function(data) {
$('#IpAddress').val(data.ip);
});
$.dobPicker({
daySelector: '#dobday',
/* Required */
monthSelector: '#dobmonth',
/* Required */
yearSelector: '#dobyear',
/* Required */
dayDefault: 'Day',
/* Optional */
monthDefault: 'Month',
/* Optional */
yearDefault: 'Year',
/* Optional */
minimumAge: 18,
/* Optional */
maximumAge: 100 /* Optional */
});
});
</script>
<script>
window.dataLayer = window.dataLayer || [];
$.dataLayer.push({
'event':'ec_formsubmit',
'enhanced_conversion_data': {
first_name: $('#firstname').val(),
last_name: $('#lastname').val(),
phone_number: $('#phone').val(),
email_address: $('#email').val(),
street: $('#street').val(),
city: $('#city').val(),
postal_code: $('#zip').val(),
dobday: $('#dobday').val(),
dobmonth: $('#dobmonth').val(),
dobyear: $('#dobyear').val(),
date_of_birth: $('#dob').val(),
plan_condition: $('.planConditions').val(),
plan_option: $('.planOption').val(),
}
})
</script>
<!--Vendor-JS-->
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.bundle.min.js" integrity="sha384-MrcW6ZMFYlzcLA8Nl+NtUVF0sA7MsXsP1UyJoMp4YLEuNSfAP+JcXn/tWtIaxVXM" crossorigin="anonymous"></script>
<!--Plugin-JS-->
</body>
</html>