{% extends 'layout.twig' %}

{% block body %}
	<section class="inner-page-banner bg-common inner-page-top-margin" data-bg-image="/images/preventivi.jpg" style="background-image: url(/images/preventivi.jpg);">
		<div class="container">
			<div class="row">
				<div class="col-12">
					<div class="breadcrumbs-area">
						<h1>Richiesta Informazioni:</h1>
						<ul>
							<li><a href="/">Home</a></li>
							<li><a href="/preventivi">Preventivi & Informazioni</a></li>
						</ul>
					</div>
				</div>
			</div>
		</div>
	</section>
	<section class="departments-wrap-layout3 bg-accent100 bg-common">
		<div class="container">
			<div class="section-heading heading-dark text-center heading-layout1">
				<h2>Informazioni per verifiche delle attrezzature di sollevamento (D.Lgs 81/08 art.71 comma 11)</h2>
			</div>
			<div class="contact-box-layout1">
				<h2 class="col-md-12 title title-bar-primary2">ANAGRAFICA</h2>
				<form class="contact-form-box" id="monitoraggio_campi_elettromagnetici" name="monitoraggio_campi_elettromagnetici" method="POST" action="/preventivi/invioRichiesta">
					<input type="hidden" class="fo-form-control form-control" id="tipologia" name="tipologia" value="Informazioni per verifiche delle attrezzature di sollevamento (D.Lgs 81/08 art.71 comma 11)" >
                    <div class="row">
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="ragione_sociale" name="ragione_sociale" placeholder="Ragione Sociale" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="indirizzo" name="indirizzo" placeholder="Indirizzo" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="citta" name="citta" placeholder="Citt&agrave;" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="telefono" name="telefono" placeholder="Telefono" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="fax" name="fax" placeholder="Fax" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="pec" name="pec" placeholder="Pec" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="piva_or_cf" name="piva_or_cf" placeholder="P.Iva o C.F." required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="attivita" name="attivita" placeholder="Attivit&agrave; svolta" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="referente_tecnico" name="referente_tecnico" placeholder="Referente tecnico" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="tel_ref" name="tel_ref" placeholder="Telefono referente" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="fax_ref" name="fax_ref" placeholder="Fax referente" required>
						</div>
						<div class="col-md-4 form-group">
							<input type="text" class="fo-form-control form-control" id="email_ref" name="email_ref" placeholder="Mail referente" required>
						</div>
						<h2 class="col-md-12 title title-bar-primary2 mt-3">UBICAZIONE IMPIANTO (se diverso da sede)</h2>
						<div class="col-md-12 form-group">
							<input type="text" class="fo-form-control form-control" id="indirizzoimpianto" name="indirizzoimpianto" placeholder="Indirizzo" required>
						</div>
						<h2 class="col-md-12 title title-bar-primary2 mt-3">TIPO DI VERIFICA RICHIESTA</h2>
						<div class="col-md-12 form-group">
							<div class="form-check">
								<input class="form-check-input" type="checkbox" id="prima_verifica" name="prima_verifica">
								<label class="form-check-label" for="prima_verifica">
									Prima verifica/messa in servizio
								</label>
							</div>
						</div>
						<div class="col-md-12 form-group">
							<div class="form-check">
								<input class="form-check-input" type="checkbox" id="verifica_periodica" name="verifica_periodica">
								<label class="form-check-label" for="verifica_periodica">
									Verifica periodica
								</label>
							</div>
						</div>
                        <h2 class="col-md-12 title title-bar-primary2 mt-3">Dati attrezzature: (numero, tipo, marca, modello...)	</h2>
                        <div class="col-md-12 form-group">
                            <textarea class="textarea fo-form-control form-control" id="note" name="note" placeholder="Numero, tipo, marca, modello..." maxlength="500" rows="7" cols="20" required></textarea>
                        </div>
                        <div class="col-md-12 form-group">
							<div class="form-check">
								<input class="form-check-input" type="checkbox" id="ok_privacy" name="ok_privacy" required>
								<label class="form-check-label" for="ok_privacy">
									Conferma di lettura dell' <a href="#">INFORMATIVA PRIVACY</a>
								</label>
							</div>
						</div>
                        <div class="col-12 form-group margin-b-none">
                            <button type="submit" id="" name="" class="item-btn">Invia</button>
                        </div>
					</div>
				</form>
			</div>
		</div>
	</section>
{% endblock %}