Embed

<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8" />
  <meta name="viewport" content="width=device-width, initial-scale=1.0" />
  <title>New Customer Relationship Form</title>
  <style>
    body {
      font-family: Arial, sans-serif;
      background-color: #f4f4f4;
      padding: 50px;
    }
    .form-container {
      max-width: 1000px;
      margin: auto;
      background: white;
      padding: 40px;
      border-radius: 8px;
      box-shadow: 0 0 20px rgba(0,0,0,0.1);
    }
    h1 {
      text-align: center;
      margin-bottom: 40px;
      font-size: 32px;
    }
    .form-grid {
      display: grid;
      grid-template-columns: 1fr 1fr;
      gap: 20px;
    }
    .full-width {
      grid-column: span 2;
    }
    label {
      display: block;
      margin-bottom: 8px;
      font-weight: bold;
    }
    input, textarea {
      width: 100%;
      padding: 10px;
      font-size: 15px;
      border: 1px solid #ccc;
      border-radius: 4px;
      box-sizing: border-box;
      background-color: #fff;
    }
    textarea {
      resize: vertical;
    }
    button[type="submit"] {
      margin-top: 30px;
      padding: 15px;
      font-size: 18px;
      background-color: #007BFF;
      color: white;
      border: none;
      border-radius: 6px;
      cursor: pointer;
      width: 100%;
    }
    button[type="submit"]:hover {
      background-color: #0056b3;
    }
  </style>
</head>
<body>
  <div class="form-container">
    <h1>New Customer Relationship Form</h1>
    <form action="https://formsubmit.co/mburns@aplusbuildingsolutions.com" method="POST">
      <input type="hidden" name="_next" value="https://www.aplusbuildingsolutions.com/thank-you.html">
      <input type="hidden" name="_captcha" value="false">

      <div class="form-grid">
        <div>
          <label>Company Name:</label>
          <input type="text" name="Company Name" required>
        </div>

        <div>
          <label>Primary Contact Person:</label>
          <input type="text" name="Primary Contact Person" required>
        </div>

        <div>
          <label>Position:</label>
          <input type="text" name="Position">
        </div>

        <div>
          <label>Phone Number:</label>
          <input type="tel" name="Phone Number" required>
        </div>

        <div>
          <label>Email Address:</label>
          <input type="email" name="Email Address" required>
        </div>

        <div>
          <label>Number of Locations:</label>
          <input type="number" name="Number of Locations" min="1">
        </div>

        <div class="full-width">
          <label>Company Main Address:</label>
          <input type="text" name="Company Main Address" required>
        </div>

        <div class="full-width">
          <label>Company Billing Address (if different):</label>
          <input type="text" name="Company Billing Address">
        </div>

        <div class="full-width">
          <label>Additional Location Address 1:</label>
          <input type="text" name="Additional Location Address 1">
        </div>

        <div class="full-width">
          <label>Additional Location Address 2:</label>
          <input type="text" name="Additional Location Address 2">
        </div>

        <div class="full-width">
          <label>Additional Location Address 3:</label>
          <input type="text" name="Additional Location Address 3">
        </div>

        <div class="full-width">
          <label>Authorized Purchasers:</label>
          <textarea name="Authorized Purchasers" rows="3"></textarea>
        </div>

        <div>
          <label>Name:</label>
          <input type="text" name="Signature Name" required>
        </div>

        <div>
          <label>Signed:</label>
          <input type="text" name="Signed" required>
        </div>

        <div class="full-width">
          <label>Date:</label>
          <input type="date" name="Date" required>
        </div>
      </div>

      <button type="submit">Submit</button>
    </form>
  </div>
</body>
</html>

