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<div style="max-width: 700px;"> <div class="text-center bg-light p-3 border border-bottom-0"> <h5 class="mb-0">Contact Us</h5> </div> <form class="reg-form p-4 bg-white border" method="post" id="registrationForm"> <div class="row mb-3" id="success-message" style="display: none;"> <div class="alert alert-success" role="alert"> Thank you for contacting us! </div> </div> <div class="row mb-3"> <div class="col-6"> <!--has-error--> <input class="form-control" type="text" id="first_name" name="first_name" placeholder="First name" required /> <span class="help-block" for="first_name"></span> <!-- error massage --> </div> <div class="col-6"> <!--has-error--> <input class="form-control" type="text" id="last_name" name="last_name" placeholder="Last name" required /> <span class="help-block" for="last_name"></span> <!-- error massage --> </div> </div> <div class="row mb-3"> <div class="col-12"> <!--has-error--> <input class="form-control" type="text" id="email" name="email" placeholder="E-mail" required /> <span class="help-block" for="email"></span> <!-- error massage --> </div> </div> <div class="row mb-3"> <div class="col-4"> <!--has-error--> <input class="form-control" value="+254" disabled type="text" id="post_code" name="post_code" placeholder="Country code" required /> <span class="help-block" for="post_code"></span> <!-- error massage --> </div> <div class="col-8"> <!--has-error--> <input class="form-control" type="text" id="phone" name="phone" placeholder="Phone number" required /> <span class="help-block" for="phone"></span> <!-- error massage --> </div> </div> <div class="row"> <div class="col-12"> <input class="btn btn-danger w-100" type="submit" value="Submit" /> </div> </div> </form> </div> <link href="https://cdn.jsdelivr.net/npm/bootstrap@5.0.2/dist/css/bootstrap.min.css" rel="stylesheet"> <style> /* .reg-form { direction: rtl; } */ .form-check .form-check-input { float: right; margin-left: 0; margin-right: -1.5em; } .form-select { background-position: left .75rem center; } a { color: #000; text-decoration: underline; } .form-control { padding: 0.75rem .75rem; } .btn { padding: .75rem .75rem; } .has-error *, .help-block { color: #cd2124 !important; } .help-block { width: 100%; margin-top: .25rem; font-size: 80%; text-transform: lowercase; } .has-error .custom-file-label, .has-error .input-group-text, .has-error input, .has-error select, .has-error textarea { border-color: #cd2124; background: rgba(205, 33, 36, .2); } </style> <script src="https://cdn.jsdelivr.net/npm/jquery@3.5.1/dist/jquery.min.js"></script> <script type="text/javascript"> $(document).ready(function () { $('#registrationForm').submit(function (e) { e.preventDefault(); var first_name = $("input[name=first_name]").val(); var last_name = $("input[name=last_name]").val(); var email = $("input[name=email]").val(); var phone = $("input[name=phone]").val(); var country = "KE"; var post_code = 254; var massage = $("input[name=massage]").val(); $("#registrationForm").find("input, button, select").attr('disabled', true); var campaign_name = ""; var campaign_name_arr = $(location).attr("href").split('/').pop().split('?'); if (campaign_name_arr !== undefined) { campaign_name = campaign_name_arr[0]; } var str = window.location.search.replace('?', '');; var extras = ""; for (let entry of str.split("&")) { let pair = entry.split("="); extras += '/' + pair[1]; } campaign_name += extras; $.ajax({ type: "POST", url: "https://portal.ingotbrokersafrica.com/api/v1/ingot/create-campaign-lead-post", dataType: 'json', headers: { 'Access-Control-Allow-Origin': '*', }, data: { 'first_name': first_name, 'last_name': last_name, 'email': email, 'country': country, 'post_code': post_code, 'phone': phone, 'massage': massage, 'campaign_name': campaign_name, 'referral': '11', }, success: function (response, textStatus, jqXHR) { if (!response.success) { $.each(response.data, function (key, value) { $("#registrationForm").find("input, button, select") .attr('disabled', false); $('#' + key).parent().addClass('has-error'); $('#' + key).next().text(value); }); } else { window.location.href = "https://campaign.ingotbrokersafrica.com/kenya-success" } }, error: function (jqXHR, textStatus, errorThrown) { $("#registrationForm").find("input, button, select").attr('disabled', false); } }); }); }); </script>