1#@!#!123s

: / home / u193541357 / domains / racysanitaryware.com / public_html /
Filename : warranty-registration.php
back
<?php include('header.php'); ?>

<div class="hero-scrolling-wrapper">
    <div class="hero-scrolling-target">
        <div class="hotel-hero">
            <div class="hotel-hero-layout">
                <h1 data-w-id="78ea0222-c417-1753-ae49-6aa0f1a4bb9e" class="heading is-hotel-hero-title hauora-font">Warranty
                    <span class="span-brown-10 tomatoes-font">Claim</span>
                </h1>
            </div>
            <div class="hotel-hero-slider">
                <div class="parallax-slider">
                    <div class="parallax-slider-sticky">
                        <div class="parallax-slider-size">
                            <div class="parallax-slider-backgrounds">
                                <div class="slider-inner">
                                    <div class="slider-container">
                                        <div class="slider-image-block-1">
                                            <img loading="eager" src="assets/images/transform.jpg" alt="" class="slider-image is-1st">
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="hotel-hero-overlay-color"></div>
            </div>
        </div>
    </div>
    <div class="hero-scrolling-trigger"></div>
</div>

<section id="information" class="section overflow-visible">
    <div class="content-component">
        <div class="container">
            <div class="padding in-content-component">
                <div class="vertical-flex with-gap-4em is-align-center">
                    <h2 class="heading hauora-font ">Fill the Form to get your claim</h2>
                </div>
            </div>
        </div>
    </div>
    <div class="contact-content-row">
        <div id="the-form" class="contact-form-column">
            <div class="contact-content-form">
                <div class="booking-form w-form">
                    <form id="wf-form-Dealer-Form" name="wf-form-Dealer-Form" data-name="Dealer Form" method="post" enctype="multipart/form-data" class="booking-form-layout">
                        <div class="booking-form-fields">
                            <h6 style="width:100%;text-align:center;">User Information</h6>
                            <!-- User Information -->
                            <div class="form-field"><label for="fullname" class="field-label">Full Name</label>
                                <input class="text-field w-input" maxlength="256" name="fullname" placeholder="" type="text" id="fullname" required>
                            </div>
                            <div class="form-field"><label for="email" class="field-label">Email</label>
                                <input class="text-field w-input" maxlength="256" name="email" placeholder="" type="email" id="email" required>
                            </div>
                            <div class="form-field"><label for="contact" class="field-label">Contact No</label>
                                <input class="text-field w-input" maxlength="15" name="contact" placeholder="" type="tel" id="contact" required>
                            </div>
                            <div class="form-field"><label for="address1" class="field-label">Address Line 1</label>
                                <input class="text-field w-input" maxlength="256" name="address1" type="text" id="address1" required>
                            </div>
                            <div class="form-field"><label for="address2" class="field-label">Address Line 2</label>
                                <input class="text-field w-input" maxlength="256" name="address2" type="text" id="address2" required>
                            </div>
                            <div class="form-field"><label for="city" class="field-label">City</label>
                                <input class="text-field w-input" maxlength="100" name="city" type="text" id="city" required>
                            </div>
                            <div class="form-field"><label for="state" class="field-label">State</label>
                                <input class="text-field w-input" maxlength="100" name="state" type="text" id="state" required>
                            </div>
                            <div class="form-field"><label for="pincode" class="field-label">Pincode</label>
                                <input class="text-field w-input" maxlength="10" name="pincode" type="text" id="pincode" required>
                            </div>
                            <h6 style="width:100%;text-align:center;">Dealer Information</h6>
                            <!-- Dealer Information -->
                            <div class="form-field"><label for="dealer-name" class="field-label">Dealer Name</label>
                                <input class="text-field w-input" maxlength="256" name="dealer-name" type="text" id="dealer-name" required>
                            </div>
                            <div class="form-field"><label for="dealer-address1" class="field-label">Dealer Address 1</label>
                                <input class="text-field w-input" maxlength="256" name="dealer-address1" type="text" id="dealer-address1" required>
                            </div>
                            <div class="form-field"><label for="dealer-address2" class="field-label">Dealer Address 2</label>
                                <input class="text-field w-input" maxlength="256" name="dealer-address2" type="text" id="dealer-address2" required>
                            </div>
                            <div class="form-field"><label for="dealer-city" class="field-label">Dealer City</label>
                                <input class="text-field w-input" maxlength="100" name="dealer-city" type="text" id="dealer-city" required>
                            </div>
                            <div class="form-field"><label for="dealer-state" class="field-label">Dealer State</label>
                                <input class="text-field w-input" maxlength="100" name="dealer-state" type="text" id="dealer-state" required>
                            </div>
                            <div class="form-field"><label for="dealer-pincode" class="field-label">Dealer Pincode</label>
                                <input class="text-field w-input" maxlength="10" name="dealer-pincode" type="text" id="dealer-pincode" required>
                            </div>
                            <div class="form-field"><label for="dealer-contact" class="field-label">Dealer Contact No</label>
                                <input class="text-field w-input" maxlength="15" name="dealer-contact" type="tel" id="dealer-contact" required>
                            </div>
                            <div class="form-field"><label for="invoice-number" class="field-label">Invoice Number</label>
                                <input class="text-field w-input" maxlength="50" name="invoice-number" type="text" id="invoice-number" required>
                            </div>
                            <div class="form-field"><label for="invoice-date" class="field-label">Invoice Date</label>
                                <input class="text-field w-input" name="invoice-date" type="date" id="invoice-date" required>
                            </div>
                            <div class="form-field"><label for="product-details" class="field-label">Product Details</label>
                                <textarea class="text-field is-area-field w-input" name="product-details" id="product-details" maxlength="5000" required></textarea>
                            </div>
                            <div class="form-field"><label for="quantity" class="field-label">Quantity</label>
                                <input class="text-field w-input" name="quantity" type="number" id="quantity" required>
                            </div>
                            <div class="form-field"><label for="upload-invoice" class="field-label">Upload Invoice (PDF/JPG)</label>
                                <input class="text-field w-input" name="upload-invoice" type="file" id="upload-invoice" accept=".pdf,.jpg" required>
                            </div>
                        </div>
                        <div class="submit-button-block">
                            <input type="submit" data-wait="Please wait..." class="submit-button w-button" value="Submit">
                        </div>
                    </form>
                    <div class="success-message w-form-done">
                        <div class="success-message-text hauora-font">Thank you for submitting the dealer information!</div>
                        <p class="paragraph is-extra-large hauora-font">We will review and respond within 24 business hours.</p>
                    </div>
                    <div class="error-message w-form-fail">
                        <div class="error-message-text">Oops! Something went wrong while submitting the form.</div>
                    </div>
                </div>
            </div>
        </div>
    </div>
    <div class="gradient-backgrounds">
        <div class="gradient-background-1"></div>
    </div>
</section>

<?php include('footer.php'); ?>