@include('includes.partials.messages')
{!! Form::open(array('method' => 'POST', 'id' => 'frm_enter_to_win')) !!}
{!! Form::label('email', 'Email Address:') !!} *
{!! Form::text('email', null, ['type' => 'email', 'required' => 'required', 'class' => 'form-control', 'placeholder' => 'Enter email address ...', 'id' => 'sp_email']) !!}
{!! Form::label('first_name', 'First Name:') !!} *
{!! Form::text('first_name', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter first name ...']) !!}
{!! Form::label('last_name', 'Last Name:') !!} *
{!! Form::text('last_name', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter last name ...']) !!}
{!! Form::label('company', 'Company/Institute:') !!} *
{!! Form::text('company', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter company/institute name ...']) !!}
{!! Form::label('phone', 'Phone:') !!} *
{!! Form::text('phone', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter phone ...']) !!}
{!! Form::label('address', 'Address:') !!} *
{!! Form::text('address', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter address ...']) !!}
{!! Form::label('city', 'City:') !!} *
{!! Form::text('city', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter city ...']) !!}
{!! Form::label('state', 'State:') !!} *
{!! Form::select('state',
$data['states']
,null
,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('zip', 'Zip / Post Code:') !!} *
{!! Form::text('zip', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter zip / post code ...']) !!}
{!! Form::label('role', 'Your Role:') !!} *
{!! Form::select('role',
['Veterinarian' => 'Veterinarian', 'Dentist' => 'Dentist', 'Technician' => 'Technician', 'Office Manager' => 'Office Manager', 'Clinic Owner' => 'Clinic Owner', 'Associated with Hospital' => 'Associated with Hospital', 'Other' => 'Other']
,null
,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('role', 'Your Speciality:') !!} *
{!! Form::select('speciality',
['Dental' => 'Dental', 'Orthopedic' => 'Orthopedic', 'Soft Tissue' => 'Soft Tissue', 'Spay Neuter' => 'Spay Neuter']
,null
,['id' => 'newsletter-speciality', 'class'=>'form-control', 'required' => 'required', 'placeholder' => 'Your speciality ...']) !!}
{!! Form::label('comments', 'Additional Comments:') !!}
{!! Form::textarea('comments', null,['class'=>'form-control', 'placeholder'=>'Additional Comments ...', 'rows' => '3']) !!}
Submit
Please fill complete details in order to make your entery eligible for the draw.