<?php $__env->startSection('jsPageBottom'); ?>
<script type="text/javascript">var logout = <?php echo (Session::has('logout'))?1:0; ?></script>
<script type="text/javascript">var requireLogin = <?php echo (Session::has('requireLogin'))?1:0; ?></script>
<script type="text/javascript">var modal = <?php echo (Session::has('modal'))?1:0; ?></script>
<?php echo HTML::script('admin/template/js/jquery.bxslider.js'); ?>

<?php echo HTML::script('admin/template/js/home.js'); ?>

<?php $__env->stopSection(); ?>
<?php $__env->startSection('cssPage'); ?>
<?php $__env->stopSection(); ?>

<?php $__env->startSection('pageContent'); ?>
<div id="central-body" class="contact-us">
    <div id="title-background">
        <div id="title-body-contact">
            <p id="text-left-body-contact"> CONTACT US </p>
            <p id="text-right-body-contact"> Use this form to send your questions or comments,</br>
                A One-Step Lien Search representative will respond to your request momentarily. </p>
        </div>
    </div>
    <div id="container-center-contact">
        <?php echo Form::open(['route'=>['contactus'], 'files'=>true , 'class'=>'form-horizontal row-border', 'method' =>'post']); ?>

            <div id="container-table-contact">
                <div id="column" class="row">
                    <div class="col-md-3">
                        <p>Your Name:</p>
                        <?php echo Form::text('your_name',Input::get('your_name'), ['class'=>'form-control', 'id'=>'your-name-contact-us', 'required'=>'required']); ?>

                    </div>
                    <div class="company_name">
                        <div class="col-md-3">
                            <p>Company Name:</p>
                            <?php echo Form::text('company_name',Input::get('company_name'), ['class'=>'form-control', 'id'=>'company-name-contact-us', 'required'=>'required']); ?>

                        </div>
                    </div>
                    <div class="col-md-3">
                        <p> Email: </p>
                        <?php echo Form::text('email',Input::get('email'), ['class'=>'form-control', 'id'=>'email-contact-us', 'required'=>'required']); ?>

                    </div>
                </div>
                <div id="column" class="row">
                    <div class="col-md-6">
                        <p>Address:</p>
                        <?php echo Form::text('address',Input::get('address'), ['class'=>'form-control', 'id'=>'address-contact-us']); ?>

                    </div>
                    <div class="col-md-3">
                        <p>City:</p>
                        <?php echo Form::text('city',Input::get('city'), ['class'=>'form-control', 'id'=>'city-contact-us']); ?>

                    </div>
                    <div class="state">
                        <div class="col-md-3">
                            <p>State:</p>
                            <?php echo Form::select('state',array_merge(array('0'=>"Select Option"),$state) , null, ['class' => 'form-control select']); ?>

                        </div>
                    </div>
                </div>
                <div class="telf-section">
                    <div id="column" class="row">
                        <div class="col-md-3"><p>Zip code:</p></div>
                        <div class="col-md-3"><p>Daytime Phone No:</p></div>
                        <div class="col-md-1 extension"><p>Ext:</p></div>
                        <div class="col-md-3"><p>Fax Number:</p></div>
                        <div class="zipcode">
                            <div class="col-md-3">
                                <?php echo Form::text('zip_code',Input::get('zip_code'), ['class'=>'form-control', 'id'=>'zip-code-contact-us']); ?>

                            </div>
                        </div>
                        <div class="col-md-1">
                            <?php echo Form::text('day_time[0]',Input::get('day_time.0'), ['class'=>'form-control', 'id'=>'fax-number', 'maxlength'=>'3', 'required'=>'required']); ?>

                        </div>
                        <div class="col-md-1">
                            <?php echo Form::text('day_time[1]',Input::get('day_time.1'), ['class'=>'form-control', 'id'=>'fax-number', 'maxlength'=>'3', 'required'=>'required']); ?>

                        </div>
                        <div class="col-md-1">
                            <?php echo Form::text('day_time[2]',Input::get('day_time.2'), ['class'=>'form-control', 'id'=>'fax-number', 'maxlength'=>'4', 'required'=>'required']); ?>

                        </div>
                        <div class="ext">
                            <div class="col-md-1">
                                <?php echo Form::text('ext',Input::get('ext'), ['class'=>'form-control', 'id'=>'ext', 'maxlength'=>'5']); ?>

                            </div>
                        </div>
                        <!-- 2 Espacios en blanco -->
                        <div class="col-md-1 espacios"><p></p></div>
                        <div class="col-md-1 espacios"><p></p></div>
                        <!-- -->
                        <div class="ext">
                            <div class="col-md-1">
                                <?php echo Form::text('fax_number[0]',Input::get('fax_number.0'), ['class'=>'form-control-especial', 'id'=>'fax-number', 'size'=>'3', 'maxlength'=>'3']); ?>

                            </div>
                            <div class="col-md-1">
                                <?php echo Form::text('fax_number[1]',Input::get('fax_number.1'), ['class'=>'form-control-especial', 'id'=>'fax-number', 'size'=>'3', 'maxlength'=>'3']); ?>

                            </div>
                            <div class="col-md-1">
                                <?php echo Form::text('fax_number[2]',Input::get('fax_number.2'), ['class'=>'form-control-especial', 'id'=>'fax-number', 'size'=>'4', 'maxlength'=>'4']); ?>

                            </div>
                        </div>
                    </div>
                </div>
                <div id="column" class="row">
                    <div class="col-md-6">
                        <p>Comments or Questions:</p>
                        <?php echo Form::textarea('comments_or_questions',Input::get('comments_or_questions'), ['class'=>'form-control', 'id'=>'comments-or-questions-contact-us', 'size'=>'3x5']); ?>

                    </div>
                </div>
                <div id="column-bottom" class="row">
                    <div class="col-md-4"><p>&nbsp;</p></div>
                    <div class="col-md-2"><button id="button-submit-form" name="button-submit-form" type="submit" class="btn btn-default">Submit</button></div>
                    <div class="col-md-2"><button id="button-submit-form" name="button-cancel-form" type="reset" class="btn btn-default">Clear</button></div>
                    <div class="col-md-4"><p>&nbsp; </p></div>
                </div>
            <?php echo Form::close(); ?>

            </div>
        </form>
    </div>
</div>
    <?php echo $__env->make('site.modal-windows.contactus', array_except(get_defined_vars(), array('__data', '__path')))->render(); ?>
    <?php echo $__env->make('helpers.footer', array_except(get_defined_vars(), array('__data', '__path')))->render(); ?>
<?php $__env->stopSection(); ?>

<?php echo $__env->make('helpers.base', array_except(get_defined_vars(), array('__data', '__path')))->render(); ?>