Registration Form saury

REGISTRATION FORM

@if(Session::has('error') && !Session::get('error')) {{ $msg }} @elseif(Session::has('error') && Session::get('error')) {{ $msg }} @endif

Company Name:

{{ Form::text('company_name', null, ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('company_name') }}

Contact Name:

{{ Form::text('contact_name', null, ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('contact_name') }}

Company Address:

{{ Form::text('address', null, ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('address') }}

State:

City:

Zip Code:

{{ Form::select('state_id', ($select + $states), null, ['id'=>'state_id', 'class' => 'form-control']) }} {{ $errors->first('state_id') }}

{{ Form::select('city_id', $select, null, ['id'=>'city_id', 'class' => 'form-control']) }} {{ $errors->first('city_id') }}

{{ Form::text('zipcode', null, ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('zipcode') }}

Email:

{{ Form::text('email', null, ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('email') }}

Primary Contact Phone:

{{ Form::text('phone[1]', Input::old('phone.1'), ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('phone') }}

{{ Form::text('phone[2]', Input::old('phone.2'), ['id'=>'', 'class' => 'form-control']) }}

{{ Form::text('phone[3]', Input::old('phone.3'), ['id'=>'', 'class' => 'form-control']) }}

Ext:

{{ Form::text('phone[ext]', Input::old('phone.ext'), ['id'=>'', 'class' => 'form-control']) }}

Fax:

{{ Form::text('fax[1]', Input::old('fax.1'), ['id'=>'', 'class' => 'form-control']) }} {{ $errors->first('fax') }}

{{ Form::text('fax[2]', Input::old('fax.2'), ['id'=>'', 'class' => 'form-control']) }}

{{ Form::text('fax[3]', Input::old('fax.3'), ['id'=>'', 'class' => 'form-control']) }}

How did you hear about us

Seminar/Conference; if so witch one?:

Referral; if so from whom so we can thank them?:

Internet Search,which search engine?:

Other: