Brochure Request Add New Row Edit ElementClone ElementAdvanced Element OptionsMoveRemove Element Get Your FREE Copy of “The Ultimate Teacher’s Toolkit” [headline style="8" align="center" headline_tag="h2"]Get Your FREE Copy of "The Ultimate Teacher's Toolkit"[/headline] Add Element Add New Row Edit ElementClone ElementAdvanced Element OptionsMoveRemove Element [custom_html] Brochure Request Name * Last Name * Phone * Email * Learn More Information FREE Physical Book Online Demo (20 mins) School / Company * Address * Town / City * County * Postcode * Send Your Request [/custom_html] [custom_html]<form class="form-view " id="agile-form" action="https://wrigglyreaders.agilecrm.com/formsubmit" style="max-width:450px;" method="GET"> <fieldset> <!-- Form Name --> <legend class="agile-hide-formname">Brochure Request</legend> <p class="agile-form-description"></p> <div style="display: none; height: 0px; width: 0px;"> <input type="hidden" id="_agile_form_name" name="_agile_form_name" value="Brochure Request"/> <input type="hidden" id="_agile_domain" name="_agile_domain" value="wrigglyreaders"/> <input type="hidden" id="_agile_api" name="_agile_api" value="a4hnnfmosv52ijgakkd113r60q"/> <input type="hidden" id="_agile_redirect_url" name="_agile_redirect_url" value="https://www.wrigglyreaders.com/brochure-thanks"/> <input type="hidden" id="_agile_document_url" name="_agile_document_url" value=""/> <input type="hidden" id="_agile_confirmation_msg" name="_agile_confirmation_msg" value="Great! Thanks for filling out the form."/> <input type="hidden" id="_agile_form_id_tags" name="tags" value="AC02_demo-step2"/> <input type="hidden" id="_agile_form_id" name="_agile_form_id" value="5650850286403584"/> </div> <style> .agile-twin-group .agile-group {width:49%; float:left; clear:both; disaply:inline-block} </style> <!-- Text input--> <div class="agile-twin-group"> <div class="agile-group required-control"> <label class="agile-label" for="firstname">Name<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="firstname" name="first_name" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="lastname">Last Name<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="lastname" name="last_name" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="phone">Phone<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="phone" name="phone" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="email">Email<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="email" name="email" type="email" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Multiple Checkboxes --> <div class="agile-group agile-form-inlinecheckboxes"> <label class="agile-label" for="br-options_1511290239791">Learn More Information</label> <div class="agile-field agile-field-xlarge agile-height-default"> <div> <label for="br-options_1511290239791-0" class="i-checks"> <input type="checkbox" name="br-options_1511290239791-0" id="br-options_1511290239791-0" value="FREE Physical Book" checked="checked"/><i></i> FREE Physical Book </label> </div> <div> <label for="br-options_1511290239791-1" class="i-checks"> <input type="checkbox" name="br-options_1511290239791-1" id="br-options_1511290239791-1" value="Online Demo (20 mins)"/><i></i> Online Demo (20 mins) </label> </div> </div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="br-company">School / Company<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="br-company" name="company" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="address">Address<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="address" name="address" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="city">Town / City<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="city" name="city" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="county">County<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="county" name="state" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!-- Text input--> <div class="agile-group required-control"> <label class="agile-label" for="postcode">Postcode<span class="agile-span-asterisk"> *</span></label> <div class="agile-field-xlarge agile-field"> <input maxlength="250" id="postcode" name="zip" type="text" placeholder="" class="agile-height-default" required=""/> </div> <div class="agile-custom-clear"></div> </div> <!--recaptcha aglignment--> <!-- Button --> <div class="agile-group"> <label class="agile-label"> </label> <div class="agile-field agile-button-field"> <button type="submit" class="agile-button">Send Your Request</button> <br/><span id="agile-error-msg"></span> </div> </div> </fieldset> </form> <script type="text/javascript"> (function(a){var b=a.onload,p=true;isCaptcha=false;if(p){a.onload="function"!=typeof b?function(){try{_agile_load_form_fields()}catch(a){}}:function(){b();try{_agile_load_form_fields()}catch(a){}}};var formLen=document.forms.length;for(i=0;i<formLen;i++){if(document.forms.item(i).getAttribute("id")== "agile-form"){a.document.forms.item(i).onsubmit=function(a){a.preventDefault();try{_agile_synch_form_v5(this)}catch(b){this.submit()}}}}})(window); </script>[/custom_html] Add Element Add Element
