Title: Proposition

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Text: 

Souhaitez-vous un devis pour un test d'étanchéité à l'air, s'il vous plaît entrer vos coordonnées. Dans les 24 heures, vous recevrez votre devis personnalisé.
Nous sommes actifs dans toute la Belgique.
<form method="post">
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="aanspreektitel"><abbr title="<?php echo l::get('required') ?>">*</abbr>Titre:</label>
        </div>
        <div class="col-6 col-m-8">
            <select id="aanspreektitel" name="aanspreektitel" required>
                <option value>---</option>
                <option value="M.">M.</option>
                <option value="Mme.">Mme.</option>
            </select>
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="voornaam"><abbr title="<?php echo l::get('required') ?>">*</abbr>Pr&eacute;nom:</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="text" id="voornaam" name="voornaam" required>
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="naam"><abbr title="<?php echo l::get('required') ?>">*</abbr>Nom:</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="text" id="naam" name="naam" required>
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="telefoonnummer">Numero de t&eacute;l&eacute;phone:</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="text" id="telefoonnummer" name="telefoonnummer">
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="email"><abbr title="<?php echo l::get('required') ?>">*</abbr>E-mail;</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="email" id="email" name="email" required>
        </div>
    </div>
    
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <b>Adresse du site:</b>
        </div>
    </div>    
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="straat"><abbr title="<?php echo l::get('required') ?>">*</abbr>Rue:</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="text" id="straat" name="straat" required>
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="postcode"><abbr title="<?php echo l::get('required') ?>">*</abbr>Code postal:</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="text" id="postcode" name="postcode" required>
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="gemeente"><abbr title="<?php echo l::get('required') ?>">*</abbr>Ville:</label>
        </div>
        <div class="col-6 col-m-8">
            <input type="text" id="gemeente" name="gemeente" required>
        </div>
    </div>
    <div class="row">
        <div class="col-3 col-m-4 text-right">
            <label for="opmerkingen">Notes:</label>
        </div>
        <div class="col-6 col-m-8">
            <textarea id="text" name="text"></textarea>
        </div>
    </div>
    
    <div class="row">
        <div class="col-3 col-m-4 text-right">
        </div>
        <div class="col-6 col-m-8">
            <input type="submit" name="submit" value="Je suis pr&ecirc;t" style="width:inherit">
        </div>
    </div>
    
    
        
        


      
      <?php if($alert): ?>
      <div class="alert">
          <?php foreach($alert as $message): ?>
          <?php echo html($message) ?>
          <?php endforeach ?>
      </div>
      <?php endif ?>
    
    </form>

_Les champs marqu&eacute;s d'une * sont obligatoires_

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Url-key: Proposition