Get Your Free Pet Badge
Please enter your shipping details
{!! Form::label('email', 'Email Address:') !!} *
{!! Form::text('email', @$data['ses_data_1']['email'], ['onblur' => 'check_pet_badge_email(this.value);', 'type' => 'email', 'required' => 'required', 'class' => 'form-control', 'placeholder' => 'Enter email address ...', 'id' => 'sp_email']) !!}
{!! Form::label('default_shipping', 'Seems like you have already requested the free badge, would you like to order for badge by paying $5.99?') !!}
{!! Form::hidden('hd_already_exists', @$data['hd_already_exists'], ['id' => 'hd_already_exists']) !!}
{!! Form::hidden('hd_already_exists', @$data['hd_already_exists'], ['id' => 'hd_already_exists']) !!}
{!! Form::label('first_name', 'First Name:') !!} *
{!! Form::text('first_name', @$data['ses_data_1']['first_name'],['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter first name ...']) !!}
{!! Form::label('last_name', 'Last Name:') !!} *
{!! Form::text('last_name', @$data['ses_data_1']['last_name'],['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter last name ...']) !!}
{!! Form::label('company', 'Company/Institute:') !!}
{!! Form::text('company', @$data['ses_data_1']['company'],['class'=>'form-control', 'placeholder'=>'Enter company/institute name ...']) !!}
{!! Form::label('phone', 'Phone:') !!} *
{!! Form::text('phone', @$data['ses_data_1']['phone'],['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter phone ...']) !!}
{!! Form::label('address', 'Address:') !!} *
{!! Form::text('address', @$data['ses_data_1']['address'],['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter address ...']) !!}
{!! Form::label('city', 'City:') !!} *
{!! Form::text('city', @$data['ses_data_1']['city'],['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter city ...']) !!}
{!! Form::label('state', 'State:') !!} *
{!! Form::select('state',
$data['states']
,@$data['ses_data_1']['state']
,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('zip', 'Zip / Post Code:') !!} *
{!! Form::text('zip', @$data['ses_data_1']['zip'],['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter zip / post code ...']) !!}
{!! Form::label('pet_image', 'Select Pet Image:') !!} *
{{-- {!! Form::file('zip', false,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Select and Upload Pet Image ...']) !!} --}}
Select a image
