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Order.html
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Order.html
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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
<html>
<head>
<title>Order Form</title>
<link href="https://cdn.jotfor.ms/static/formCss.css?3.3.15279" rel="stylesheet" type="text/css" />
<link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.15279" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/nova.css?3.3.15279" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?themeRevisionID=5dca5ac9a5e86d17235d90c1"/>
<style type="text/css">
.form-label-left{
width:150px;
}
.form-line{
padding-top:12px;
padding-bottom:12px;
}
.form-label-right{
width:150px;
}
body, html{
margin:0;
padding:0;
background:#fff;
}
.form-all{
margin:0px auto;
padding-top:0px;
width:690px;
color:#555 !important;
font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif;
font-size:14px;
}
.form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{
color: false;
}
input[type=text]
{
border-radius: 4px
}
input[type=tel]
{
border-radius: 4px
}
input[type=text]
{
border-radius: 4px
}
</style>
<style type="text/css" id="form-designer-style">
.form-all {
font-family: Lucida Grande,Lucida Sans Unicode,Lucida Sans,Verdana,Tahoma,sans-serif, sans-serif;
}
.form-all .qq-upload-button,
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
font-family: Lucida Grande,Lucida Sans Unicode,Lucida Sans,Verdana,Tahoma,sans-serif, sans-serif;
}
.form-all .form-pagebreak-back-container,
.form-all .form-pagebreak-next-container {
font-family: Lucida Grande,Lucida Sans Unicode,Lucida Sans,Verdana,Tahoma,sans-serif, sans-serif;
}
.form-header-group {
font-family: Lucida Grande,Lucida Sans Unicode,Lucida Sans,Verdana,Tahoma,sans-serif, sans-serif;
}
.form-label {
font-family: Lucida Grande,Lucida Sans Unicode,Lucida Sans,Verdana,Tahoma,sans-serif, sans-serif;
}
.form-label.form-label-auto {
display: inline-block;
float: left;
text-align: left;
}
.form-line {
margin-top: 20px 36px 20px 36px px;
margin-bottom: 12px 36px 12px 36px px;
}
.form-all {
width: 650px;
}
.form-label-left,
.form-label-right,
.form-label-left.form-label-auto,
.form-label-right.form-label-auto {
width: 150px;
}
.form-all {
font-size: 14pxpx
}
.form-all .qq-upload-button,
.form-all .qq-upload-button,
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
font-size: 14pxpx
}
.form-all .form-pagebreak-back-container,
.form-all .form-pagebreak-next-container {
font-size: 14pxpx
}
.supernova .form-all, .form-all {
background-color: ;
border: 1px solid transparent;
}
.form-all {
color: #555;
}
.form-header-group .form-header {
color: #555;
}
.form-header-group .form-subHeader {
color: #555;
}
.form-label-top,
.form-label-left,
.form-label-right,
.form-html,
.form-checkbox-item label,
.form-radio-item label {
color: #555;
}
.form-sub-label {
color: #6f6f6f;
}
.supernova {
background-color: undefined;
}
.supernova body {
background: transparent;
}
.form-textbox,
.form-textarea,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
background-color: undefined;
}
.supernova {
background-image: none;
}
#stage {
background-image: none;
}
.form-all {
background-image: none;
}
</style>
<script>
var stateObject = {
"India": { "Delhi": ["new Delhi", "North Delhi"],
"Kerala": ["Thiruvananthapuram", "Palakkad"],
"Goa": ["North Goa", "South Goa"],
},
"Australia": {
"South Australia": ["Dunstan", "Mitchell"],
"Victoria": ["Altona", "Euroa"]
}, "Canada": {
"Alberta": ["Acadia", "Bighorn"],
"Columbia": ["Washington", ""]
},
}
window.onload = function () {
var countySel = document.getElementById("countySel"),
stateSel = document.getElementById("stateSel"),
districtSel = document.getElementById("districtSel");
for (var country in stateObject) {
countySel.options[countySel.options.length] = new Option(country, country);
}
countySel.onchange = function () {
stateSel.length = 1; // remove all options bar first
districtSel.length = 1; // remove all options bar first
if (this.selectedIndex < 1) return; // done
for (var state in stateObject[this.value]) {
stateSel.options[stateSel.options.length] = new Option(state, state);
}
}
countySel.onchange(); // reset in case page is reloaded
stateSel.onchange = function () {
districtSel.length = 1; // remove all options bar first
if (this.selectedIndex < 1) return; // done
var district = stateObject[countySel.value][this.value];
for (var i = 0; i < district.length; i++) {
districtSel.options[districtSel.options.length] = new Option(district[i], district[i]);
}
}
}
</script>
<script type="text/javascript" src="js/city_state.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/punycode/1.4.1/punycode.min.js"></script>
<script src="https://cdn.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/static/jotform.forms.js?3.3.15279" type="text/javascript"></script>
<script type="text/javascript">
JotForm.setConditions([{"action":{"field":"26","visibility":"Show"},"link":"Any","terms":[{"field":"30","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"49","visibility":"Show"},"link":"Any","terms":[{"field":"30","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"48","visibility":"Show"},"link":"Any","terms":[{"field":"30","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"37","visibility":"Show"},"link":"Any","terms":[{"field":"30","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"36","visibility":"Show"},"link":"Any","terms":[{"field":"30","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"27","visibility":"Show"},"link":"Any","terms":[{"field":"31","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"51","visibility":"Show"},"link":"Any","terms":[{"field":"31","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"50","visibility":"Show"},"link":"Any","terms":[{"field":"31","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"39","visibility":"Show"},"link":"Any","terms":[{"field":"31","operator":"equals","value":"Yes"}],"type":"field"},{"action":{"field":"38","visibility":"Show"},"link":"Any","terms":[{"field":"31","operator":"equals","value":"Yes"}],"type":"field"}]);
JotForm.init(function(){
setTimeout(function() {
$('input_23').hint('ex: myname@example.com');
}, 20);
if (window.JotForm && JotForm.accessible) $('input_22').setAttribute('tabindex',0);
/*INIT-END*/
});
JotForm.prepareCalculationsOnTheFly([null,null,{"name":"submitForm","qid":"2","text":"Place Order","type":"control_button"},null,null,{"name":"clickTo","qid":"5","text":"Place your Order here","type":"control_head"},null,null,null,null,null,null,null,null,null,null,null,null,null,{"name":"phoneNumber19","qid":"19","text":"Phone Number","type":"control_phone"},{"name":"fullName20","qid":"20","text":"Full Name","type":"control_fullname"},{"name":"deliveryAddress","qid":"21","text":"Delivery Address","type":"control_address"},{"name":"specialDelivery","qid":"22","text":"Special Delivery Instructions","type":"control_textarea"},{"name":"email23","qid":"23","text":"E-mail","type":"control_email"},{"name":"order","qid":"24","text":"Order","type":"control_fullname"},{"name":"pageBreak","qid":"25","text":"Page Break","type":"control_pagebreak"},{"name":"order26","qid":"26","text":"Order","type":"control_fullname"},null,null,null,{"name":"more","qid":"30","text":"More?","type":"control_checkbox"},null,null,null,{"name":"order34","qid":"34","text":"Order","type":"control_fullname"},{"name":"order35","qid":"35","text":"Order","type":"control_fullname"},{"name":"order36","qid":"36","text":"Order","type":"control_fullname"},{"name":"order37","qid":"37","text":"Order","type":"control_fullname"},null,null,null,null,null,null,null,null,{"name":"order46","qid":"46","text":"Order","type":"control_fullname"},{"name":"order47","qid":"47","text":"Order","type":"control_fullname"},{"name":"order48","qid":"48","text":"Order","type":"control_fullname"},{"name":"order49","qid":"49","text":"Order","type":"control_fullname"}]);
setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,null,{"name":"submitForm","qid":"2","text":"Place Order","type":"control_button"},null,null,{"name":"clickTo","qid":"5","text":"Place your Order here","type":"control_head"},null,null,null,null,null,null,null,null,null,null,null,null,null,{"name":"phoneNumber19","qid":"19","text":"Phone Number","type":"control_phone"},{"name":"fullName20","qid":"20","text":"Full Name","type":"control_fullname"},{"name":"deliveryAddress","qid":"21","text":"Delivery Address","type":"control_address"},{"name":"specialDelivery","qid":"22","text":"Special Delivery Instructions","type":"control_textarea"},{"name":"email23","qid":"23","text":"E-mail","type":"control_email"},{"name":"order","qid":"24","text":"Order","type":"control_fullname"},{"name":"pageBreak","qid":"25","text":"Page Break","type":"control_pagebreak"},{"name":"order26","qid":"26","text":"Order","type":"control_fullname"},null,null,null,{"name":"more","qid":"30","text":"More?","type":"control_checkbox"},null,null,null,{"name":"order34","qid":"34","text":"Order","type":"control_fullname"},{"name":"order35","qid":"35","text":"Order","type":"control_fullname"},{"name":"order36","qid":"36","text":"Order","type":"control_fullname"},{"name":"order37","qid":"37","text":"Order","type":"control_fullname"},null,null,null,null,null,null,null,null,{"name":"order46","qid":"46","text":"Order","type":"control_fullname"},{"name":"order47","qid":"47","text":"Order","type":"control_fullname"},{"name":"order48","qid":"48","text":"Order","type":"control_fullname"},{"name":"order49","qid":"49","text":"Order","type":"control_fullname"}]);}, 20);
</script>
</head>
<body>
<form class="" action="" method="post" name="form_200371113125437" id="200371113125437" accept-charset="utf-8" autocomplete="on">
<div role="main" class="form-all">
<ul class="form-section page-section">
<li id="cid_5" class="form-input-wide" data-type="control_head">
<div class="form-header-group ">
<div class="header-text httal htvam">
<h2 id="header_5" class="form-header" data-component="header">
Place your Order here
</h2>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_fullname" id="id_20">
<label class="form-label form-label-left form-label-auto" id="label_20" for="first_20">
Full Name
</label>
<div id="cid_20" class="form-input jf-required">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_20" name="q20_fullName20[first]" class="form-textbox validate[required]" size="10" value="" data-component="first" aria-labelledby="label_20 sublabel_20_first" required="" />
<label class="form-sub-label" for="first_20" id="sublabel_20_first" style="min-height:13px" aria-hidden="false"> First Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_20" name="q20_fullName20[last]" class="form-textbox validate[required]" size="15" value="" data-component="last" aria-labelledby="label_20 sublabel_20_last" required="" />
<label class="form-sub-label" for="last_20" id="sublabel_20_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
</span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_phone" id="id_19">
<label class="form-label form-label-left form-label-auto" id="label_19" for="input_19_area">
Phone Number
<span class="form-required">
*
</span>
</label>
<div id="cid_19" class="form-input jf-required">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="tel" id="input_19_area" name="q19_phoneNumber19[area]" class="form-textbox validate[required]" size="6" value="" data-component="areaCode" aria-labelledby="label_19 sublabel_19_area" required="" />
<span class="phone-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="input_19_area" id="sublabel_19_area" style="min-height:13px" aria-hidden="false"> Area Code </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="tel" id="input_19_phone" name="q19_phoneNumber19[phone]" class="form-textbox validate[required]" size="12" value="" data-component="phone" aria-labelledby="label_19 sublabel_19_phone" required="" />
<label class="form-sub-label" for="input_19_phone" id="sublabel_19_phone" style="min-height:13px" aria-hidden="false"> Phone Number </label>
</span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_email" id="id_23">
<label class="form-label form-label-left form-label-auto" id="label_23" for="input_23">
E-mail
<span class="form-required">
*
</span>
</label>
<div id="cid_23" class="form-input jf-required">
<input type="email" id="input_23" name="q23_email23" class="form-textbox validate[required, Email]" size="30" value="" placeholder="ex: myname@example.com" data-component="email" aria-labelledby="label_23" required="" />
</div>
</li>
<li class="form-line jf-required" data-type="control_address" id="id_21">
<label class="form-label form-label-left form-label-auto" id="label_21" for="input_21undefined">
Delivery Address
<span class="form-required">
*
</span>
</label>
<div id="cid_21" class="form-input jf-required">
<table summary="" class="form-address-table">
<tbody>
<tr>
<td colSpan="2">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="input_21_addr_line1" name="q21_deliveryAddress[addr_line1]" class="form-textbox validate[required] form-address-line" value="" data-component="address_line_1" aria-labelledby="label_21 sublabel_21_addr_line1" required="" />
<label class="form-sub-label" for="input_21_addr_line1" id="sublabel_21_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
</span>
</td>
</tr>
<tr>
<td colSpan="2">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="input_21_addr_line2" name="q21_deliveryAddress[addr_line2]" class="form-textbox form-address-line" size="46" value="" data-component="address_line_2" aria-labelledby="label_21 sublabel_21_addr_line2" required="" />
<label class="form-sub-label" for="input_21_addr_line2" id="sublabel_21_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
</span>
</td>
</tr>
<tr>
<td>
<span class="form-sub-label-container " style="vertical-align:top">
Select Country: <select name="state" id="countySel" size="1">
<option value="" selected="selected">Select Country</option>
</select>
<label class="form-sub-label" for="input_21_city" id="sublabel_21_city" style="min-height:13px" aria-hidden="false"> City </label>
</span>
</td>
<td>
<span class="form-sub-label-container " style="vertical-align:top">
Select State: <select name="countrya" id="stateSel" size="1">
<option value="" selected="selected">Please select Country first</option>
</select>
<label class="form-sub-label" for="input_21_state" id="sublabel_21_state" style="min-height:13px" aria-hidden="false"> State / Province </label>
</span>
</td>
<td>
<span class="form-sub-label-container " style="vertical-align:top">
Select State: <select name="countrya" id="stateSel" size="1">
<option value="" selected="selected">Please select Country first</option>
</select>
<label class="form-sub-label" for="input_21_state" id="sublabel_21_state" style="min-height:13px" aria-hidden="false"> State / Province </label>
</span>
</td>
</tr>
<tr>
<td>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="input_21_postal" name="q21_deliveryAddress[postal]" class="form-textbox form-address-postal" size="10" value="" data-component="zip" aria-labelledby="label_21 sublabel_21_postal" required="" />
<label class="form-sub-label" for="input_21_postal" id="sublabel_21_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label>
</span>
</td>
<td>
<span class="form-sub-label-container " style="vertical-align:top">
<br>
<br>
Select District: <select name="district" id="districtSel" size="1">
<option value="" selected="selected">Please select State first</option>
</select><br>
</span>
</td>
</tr>
</tbody>
</table>
</div>
</li>
<li id="cid_25" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container">
<button id="form-pagebreak-back_25" type="button" class="form-pagebreak-back " data-component="pagebreak-back">
Back
</button>
</div>
<div class="form-pagebreak-next-container">
<button id="form-pagebreak-next_25" type="button" class="form-pagebreak-next " data-component="pagebreak-next">
Next
</button>
</div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_25">
</div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li class="form-line jf-required" data-type="control_fullname" id="id_24">
<label class="form-label form-label-top" id="label_24" for="first_24">
Order
<span class="form-required">
*
</span>
</label>
<div id="cid_24" class="form-input-wide jf-required">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_24" name="q24_order[first]" class="form-textbox validate[required]" size="10" value="" data-component="first" aria-labelledby="label_24 sublabel_24_first" required="" />
<label class="form-sub-label" for="first_24" id="sublabel_24_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_24" name="q24_order[last]" class="form-textbox validate[required]" size="15" value="" data-component="last" aria-labelledby="label_24 sublabel_24_last" required="" />
<label class="form-sub-label" for="last_24" id="sublabel_24_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_24" name="q24_order[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_24 sublabel_24_suffix" required="" />
<label class="form-sub-label" for="suffix_24" id="sublabel_24_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_35">
<label class="form-label form-label-top" id="label_35" for="first_35"> Order </label>
<div id="cid_35" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_35" name="q35_order35[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_35 sublabel_35_first" />
<label class="form-sub-label" for="first_35" id="sublabel_35_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_35" name="q35_order35[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_35 sublabel_35_last" />
<label class="form-sub-label" for="last_35" id="sublabel_35_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_35" name="q35_order35[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_35 sublabel_35_suffix" />
<label class="form-sub-label" for="suffix_35" id="sublabel_35_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_47">
<label class="form-label form-label-top" id="label_47" for="first_47"> Order </label>
<div id="cid_47" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_47" name="q47_order47[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_47 sublabel_47_first" />
<label class="form-sub-label" for="first_47" id="sublabel_47_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_47" name="q47_order47[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_47 sublabel_47_last" />
<label class="form-sub-label" for="last_47" id="sublabel_47_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_47" name="q47_order47[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_47 sublabel_47_suffix" />
<label class="form-sub-label" for="suffix_47" id="sublabel_47_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_46">
<label class="form-label form-label-top" id="label_46" for="first_46"> Order </label>
<div id="cid_46" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_46" name="q46_order46[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_46 sublabel_46_first" />
<label class="form-sub-label" for="first_46" id="sublabel_46_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_46" name="q46_order46[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_46 sublabel_46_last" />
<label class="form-sub-label" for="last_46" id="sublabel_46_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_46" name="q46_order46[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_46 sublabel_46_suffix" />
<label class="form-sub-label" for="suffix_46" id="sublabel_46_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_34">
<label class="form-label form-label-top" id="label_34" for="first_34"> Order </label>
<div id="cid_34" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_34" name="q34_order34[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_34 sublabel_34_first" />
<label class="form-sub-label" for="first_34" id="sublabel_34_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_34" name="q34_order34[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_34 sublabel_34_last" />
<label class="form-sub-label" for="last_34" id="sublabel_34_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_34" name="q34_order34[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_34 sublabel_34_suffix" />
<label class="form-sub-label" for="suffix_34" id="sublabel_34_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_checkbox" id="id_30">
<label class="form-label form-label-left form-label-auto" id="label_30" for="input_30"> More? </label>
<div id="cid_30" class="form-input">
<div class="form-single-column" role="group" aria-labelledby="label_30" data-component="checkbox">
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox" id="input_30_0" name="q30_more[]" value="Yes" />
<label id="label_input_30_0" for="input_30_0"> Yes </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_26">
<label class="form-label form-label-top" id="label_26" for="first_26"> Order </label>
<div id="cid_26" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_26" name="q26_order26[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_26 sublabel_26_first" />
<label class="form-sub-label" for="first_26" id="sublabel_26_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_26" name="q26_order26[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_26 sublabel_26_last" />
<label class="form-sub-label" for="last_26" id="sublabel_26_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_26" name="q26_order26[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_26 sublabel_26_suffix" />
<label class="form-sub-label" for="suffix_26" id="sublabel_26_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_49">
<label class="form-label form-label-top" id="label_49" for="first_49"> Order </label>
<div id="cid_49" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_49" name="q49_order49[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_49 sublabel_49_first" />
<label class="form-sub-label" for="first_49" id="sublabel_49_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_49" name="q49_order49[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_49 sublabel_49_last" />
<label class="form-sub-label" for="last_49" id="sublabel_49_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_49" name="q49_order49[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_49 sublabel_49_suffix" />
<label class="form-sub-label" for="suffix_49" id="sublabel_49_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_48">
<label class="form-label form-label-top" id="label_48" for="first_48"> Order </label>
<div id="cid_48" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_48" name="q48_order48[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_48 sublabel_48_first" />
<label class="form-sub-label" for="first_48" id="sublabel_48_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_48" name="q48_order48[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_48 sublabel_48_last" />
<label class="form-sub-label" for="last_48" id="sublabel_48_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_48" name="q48_order48[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_48 sublabel_48_suffix" />
<label class="form-sub-label" for="suffix_48" id="sublabel_48_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_37">
<label class="form-label form-label-top" id="label_37" for="first_37"> Order </label>
<div id="cid_37" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_37" name="q37_order37[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_37 sublabel_37_first" />
<label class="form-sub-label" for="first_37" id="sublabel_37_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_37" name="q37_order37[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_37 sublabel_37_last" />
<label class="form-sub-label" for="last_37" id="sublabel_37_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_37" name="q37_order37[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_37 sublabel_37_suffix" />
<label class="form-sub-label" for="suffix_37" id="sublabel_37_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_36">
<label class="form-label form-label-top" id="label_36" for="first_36"> Order </label>
<div id="cid_36" class="form-input-wide">
<div data-wrapper-react="true">
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="first_36" name="q36_order36[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_36 sublabel_36_first" />
<label class="form-sub-label" for="first_36" id="sublabel_36_first" style="min-height:13px" aria-hidden="false"> Product # </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="last_36" name="q36_order36[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_36 sublabel_36_last" />
<label class="form-sub-label" for="last_36" id="sublabel_36_last" style="min-height:13px" aria-hidden="false"> Product Name </label>
</span>
<span class="form-sub-label-container " style="vertical-align:top">
<input type="text" id="suffix_36" name="q36_order36[suffix]" class="form-textbox" size="4" value="" data-component="suffix" aria-labelledby="label_36 sublabel_36_suffix" />
<label class="form-sub-label" for="suffix_36" id="sublabel_36_suffix" style="min-height:13px" aria-hidden="false"> Quantity </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_textarea" id="id_22">
<label class="form-label form-label-left form-label-auto" id="label_22" for="input_22"> Special Delivery Instructions </label>
<div id="cid_22" class="form-input">
<textarea id="input_22" class="form-textarea" name="q22_specialDelivery" cols="40" rows="4" data-component="textarea" aria-labelledby="label_22"></textarea>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_2">
<div id="cid_2" class="form-input-wide">
<div style="margin-left:156px" class="form-buttons-wrapper ">
<button id="input_2" type="submit" class="form-submit-button form-submit-button-steel" data-component="button" data-content="">
Place Order
</button>
</div>
</div>
</li>
<li style="display:none">
Should be Empty:
<input type="text" name="website" value="" />
</li>
</ul>
</div>
</form>
</body>
</html>
<script type="text/javascript">JotForm.ownerView=true;</script>