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<div class="insurance-banner" style="background-image: url(<?php echo base_url();?>assets/images/book-service-appointment.jpg)">
<div class="container">
<div class="row">
<div class="col-12">
<div class="banner-title-card">
<!-- <h5>protect your finances with</h5>-->
<h4 class="text-white">BOOK A<br>
SERVICE APPOINTMENT</h4>
</div>
</div>
</div>
</div>
</div>
<section class="insurance-form">
<div class="container">
<div id='crmWebToEntityForm' class='position-relative'>
<form action='<?php echo base_url();?>servicebooking' method='POST' accept-charset='UTF-8'>
<!-- Do not remove this code. -->
<div class="form-row">
<div class="col-12">
<h3>Please fill in the details :</h3>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Full_Name'>Full Name<span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'><input type='text' id='firstname' name='firstname' class="form-control" maxlength='80' required>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Mobile'>Mobile<span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'><input type='tel' id='phone' class="form-control" name='phone' maxlength='10' minlength='10' required>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Email'>Email <span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'>
<input type='email' ftype='email' id='email' name='email' class="form-control" maxlength='100'>
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">State <span style='color:red;'>*</span></label>
<select class="custom-select mr-sm-2" id='state' name='state' required>
<option value="">Select State</option>
<option value="delhi-ncr">Delhi NCR</option>
</select>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">City</label>
<select class="custom-select mr-sm-2" id='city' name='city' required>
<option value="">Select City</option>
<option value="Gurgaon">Gurgaon</option>
<option value="Faridabad">Faridabad</option>
<option value="Ghaziabad">Ghaziabad</option>
<option value="Noida">Noida</option>
<option value="Delhi">Delhi</option>
</select>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">Outlet <span style='color:red;'>*</span></label>
<select class="custom-select mr-sm-2" id='outlet' name='outlet' required>
<option value="">Select Outlets</option>
<option value="Faridabad">GURGAON WORKSHOP</option>
</select>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">Model <span style='color:red;'>*</span></label>
<select class="custom-select mr-sm-2" id='model' name='model' required>
<option value="">-Select Model-</option>
<option value="SKODA OCTAVIA">ŠKODA OCTAVIA</option>
<option value="SKODA KUSHAQ">ŠKODA KUSHAQ</option>
<option value="SKODA RAPID">ŠKODA RAPID</option>
<option value="SKODA SUPERB">ŠKODA SUPERB</option>
<option value="Other">OTHER</option>
</select>
</div>
</div>
</div>
<div class="col-md-3 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Date'>Date <span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'>
<input type='date' ftype='date' id='Date' name='date' class="form-control">
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<div class='zcwf_row'>
<div class='zcwf_col_lab'>
<label for='Vehicle'>Vehicle Registration Number <span style='color:red;'>*</span></label>
</div>
<div class='zcwf_col_fld'>
<input type='text' ftype='Vehicle-Registration' id='registration_number' name='registration_number' class="form-control">
<div class='zcwf_col_help'></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">Pickup and Drop <span style='color:red;'>*</span></label>
<select class="custom-select mr-sm-2" id='pickup' name='pickup' required>
<option value="">-Select Pickup and Drop-</option>
<option>Pickup only</option>
<option>Drop off only</option>
<option>Pickup and Drop Only</option>
<option>Not required</option>
</select>
</div>
</div>
</div>
<div class="col-md-4 mb-3">
<div class="form-group">
<div class="has-float-label">
<label for="name">Type of Service <span style='color:red;'>*</span></label>
<select class="custom-select mr-sm-2" id='servic_type' name='servic_type' required>
<option value="">-Select Service-</option>
<option> Accessories fitment </option>
<option> Body and Paint </option>
<option> Breakdown </option>
<option> Doorstep Service </option>
<option> Periodic Maintenance </option>
<option> Running Repair </option>
<option> Value Added Services </option>
<option> Others </option>
</select>
</div>
</div>
</div>
<div class="col-md-12">
<div class="form-group">
<span class="has-float-label">
<label for="text">Any Other Comments <span style='color:red;'>*</span></label>
<textarea rows="4" name="comment" placeholder="" style="width:100%; border-radius:5px; height:auto" id="car-enquiry-comment"></textarea>
</span>
</div>
</div>
<div class="col-md-12 mb-3">
<div class="form-group">
<p>Fields marked <span style='color:red;'>*</span> are Mandatory</p>
</div>
<input type="hidden" id="zc_gad" name="zc_gad" value="" />
<button class="btn btn-primary formsubmit zcwf_button" id='formsubmit' name="submit" type="submit">Submit </button>
</div>
</div>
</form>
</div>
</section>