<?php include("inc/header.php"); ?>
    <section class="inner-banner-row">
        <div class="container">
            <div class="inner-banner-sec"></div>
        </div>
    </section>
    <section class="sec5-row contact-page-row">
        <div class="container">
            <div class="contact-row">
                <div class="w-sec contact-sec">
                    <h3>Custom Order</h3>
                    <h2>Request a Quote</h2>
                    <form action="#" method="POST">
                        <div class="row">
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="name">Name *</label>
                                    <input type="text" name="name" class="form-control" placeholder="Name" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="number">Phone Number *</label>
                                    <input type="number" name="number" class="form-control" placeholder="Phone Number" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="email">Email Address *</label>
                                    <input type="email" name="email" class="form-control" placeholder="Email Address" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="company">Company Name *</label>
                                    <input type="text" name="company" class="form-control" placeholder="Company Name" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="product">Product Type *</label>
                                    <input type="text" name="product" class="form-control" placeholder="Product Type" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="quantity">Estimated Quantity *</label>
                                    <input type="text" name="quantity" class="form-control" placeholder="Estimated Quantity" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-12 col-lg-12">
                                <div class="form-group">
                                    <label for="quantity">Describe What You Need</label>
                                    <textarea name="quantity" class="form-control" placeholder="Describe What You Need"></textarea>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="quantity">Available Pickup Locations</label>
                                    <select name="location" class="form-select">
                                        <option value="1">FLORENCE - $0.00</option>
                                        <option value="2">LIBERTY HILL - $0.00</option>
                                        <option value="3">FORT WORTH - $0.00</option>
                                        <option value="4">SAN SABA - $0.00</option>
                                        <option value="5">CUSTOMER CLICKED - $0.00</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="delivery">Delivery</label>
                                    <input type="text" name="delivery" class="form-control" placeholder="Delivery" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="address">Delivery Address</label>
                                    <input type="text" name="address" class="form-control" placeholder="Delivery Address" required>
                                </div>
                            </div>
                            <div class="col-xs-12 col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label for="date">Delivery Date</label>
                                    <input type="date" name="date" class="form-control" placeholder="Delivery Date" required>
                                </div>
                            </div>
                        </div>
                        <button type="submit" class="btn btn-primary w-btn">Submit</button>
                    </form>
                </div>
            </div>
        </div>
    </section>
<?php include("inc/footer.php"); ?>