
<div id="result">
	<h1 class="mt-5 mb-5">
		Request on product &#039;&#039;
	</h1>
	<form novalidate="novalidate" method="post" name="request" class="ajaxForm" id="frmRequestProduct" action="/nl/en/product/request-product/form4.php?tx_mpqd_products%5Baction%5D=requestConfirm&amp;tx_mpqd_products%5Bcontroller%5D=Products&amp;cHash=083e99539bd1f5af277436be71231a30">
<div>
<input type="hidden" name="tx_mpqd_products[__referrer][@extension]" value="MpQd" />
<input type="hidden" name="tx_mpqd_products[__referrer][@controller]" value="Products" />
<input type="hidden" name="tx_mpqd_products[__referrer][@action]" value="request" />
<input type="hidden" name="tx_mpqd_products[__referrer][arguments]" value="YTowOnt9e354c77720c0e34e4665ea0863b5f969dc2276f1" />
<input type="hidden" name="tx_mpqd_products[__referrer][@request]" value="{&quot;@extension&quot;:&quot;MpQd&quot;,&quot;@controller&quot;:&quot;Products&quot;,&quot;@action&quot;:&quot;request&quot;}84a1d41ee49f4e6822bc61c43ebc591cc7cf22b7" />
<input type="hidden" name="tx_mpqd_products[__trustedProperties]" value="{&quot;request&quot;:{&quot;uri&quot;:1,&quot;product&quot;:1,&quot;offer&quot;:1,&quot;presentation&quot;:1,&quot;service&quot;:1,&quot;gender&quot;:1,&quot;firstName&quot;:1,&quot;lastName&quot;:1,&quot;company&quot;:1,&quot;phone&quot;:1,&quot;fax&quot;:1,&quot;email&quot;:1,&quot;street&quot;:1,&quot;zip&quot;:1,&quot;city&quot;:1,&quot;country&quot;:1,&quot;comments&quot;:1},&quot;extra&quot;:{&quot;fillStart&quot;:1,&quot;971e39b9eec77403c9a1cbfabcfcbc99293e548d&quot;:1}}f1d4c5bc95f16c095b71b305c82c41ef045d47fd" />
</div>


		<input type="hidden" name="tx_mpqd_products[request][uri]" value="" />

		<input type="hidden" name="tx_mpqd_products[request][product]" value="" />

		<h2 class="mt-5 mb-5">
			I&#039;m requesting
		</h2>

		<div class="row">
			<div class="col-md-6">
				<div class="mb-1">
					<input type="hidden" name="tx_mpqd_products[request][offer]" value="" /><input id="chkOffer" type="checkbox" name="tx_mpqd_products[request][offer]" value="1" />
					<label for="chkOffer">Quotation</label>
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-6">
				<div class="mb-1">
					<input type="hidden" name="tx_mpqd_products[request][presentation]" value="" /><input id="chkPresentation" type="checkbox" name="tx_mpqd_products[request][presentation]" value="1" />
					<label for="chkPresentation">Free demonstration</label>
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-6">
				<div class="mb-3">
					<input type="hidden" name="tx_mpqd_products[request][service]" value="" /><input id="chkService" type="checkbox" name="tx_mpqd_products[request][service]" value="1" />
					<label for="chkService">Service / Support</label>
				</div>
			</div>
		</div>

		<input autocomplete="off" type="hidden" name="tx_mpqd_products[extra][fillStart]" value="1775709349" />

		<input autocomplete="971e39b9eec77403c9a1cbfabcfcbc99293e548d" tabindex="-1" aria-hidden="true" id="txt971e39b9eec77403c9a1cbfabcfcbc99293e548d" style="position:absolute; margin:0 0 0 -999em;" type="text" name="tx_mpqd_products[extra][971e39b9eec77403c9a1cbfabcfcbc99293e548d]" value="" />

		<div class="row">
			
			<div class="col-md-2">
				<div class="mb-3">
					<label for="selGender" class="form-label required">Salutation</label>
					<select autocomplete="off" required="required" class="form-select form-control" id="selGender" name="tx_mpqd_products[request][gender]"><option value="">Please choose</option>
<option value="5">Mr.</option>
<option value="7">Ms.</option>
<option value="13">Misc.</option>
</select>
				</div>
			</div>

			
			<div class="col-md-4">
				<div class="mb-3">
					<label for="txtFirstName" class="form-label required">First name</label>
					<input autocomplete="off" required="required" class="form-control" id="txtFirstName" type="text" name="tx_mpqd_products[request][firstName]" value="" />
				</div>
			</div>

			
			<div class="col-md-6">
				<div class="mb-3">
					<label for="txtLastName" class="form-label required">Last name</label>
					<input autocomplete="off" required="required" class="form-control" id="txtLastName" type="text" name="tx_mpqd_products[request][lastName]" value="" />
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-12">
				<div class="mb-3">
					<label for="txtCompany" class="form-label required">Company</label>
					<input autocomplete="off" required="required" class="form-control" id="txtCompany" type="text" name="tx_mpqd_products[request][company]" value="" />
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-12">
				<hr />
			</div>
		</div>

		<div class="row">
			<div class="col-md-4">
				<div class="mb-3">
					<label for="txtPhone" class="form-label required">Phone</label>
					<input autocomplete="off" required="required" class="form-control" id="txtPhone" type="text" name="tx_mpqd_products[request][phone]" value="" />
				</div>
			</div>

			<div class="col-md-4">
				<div class="mb-3">
					<label for="txtFax" class="form-label">Fax</label>
					<input class="form-control" id="txtFax" type="text" name="tx_mpqd_products[request][fax]" value="" />
				</div>
			</div>

			<div class="col-md-4">
				<div class="mb-3">
					<label for="txtEmail" class="form-label required">E-Mail</label>
					<input autocomplete="off" required="required" class="form-control" id="txtEmail" type="text" name="tx_mpqd_products[request][email]" value="" />
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-6">
				<div class="mb-3">
					<label for="txtStreet" class="form-label required">Street</label>
					<input autocomplete="off" required="required" class="form-control" id="txtStreet" type="text" name="tx_mpqd_products[request][street]" value="" />
				</div>
			</div>

			<div class="col-md-2">
				<div class="mb-3">
					<label for="txtZip" class="form-label required">Zip</label>
					<input autocomplete="off" required="required" class="form-control" id="txtZip" type="text" name="tx_mpqd_products[request][zip]" value="" />
				</div>
			</div>

			<div class="col-md-4">
				<div class="mb-3">
					<label for="txtCity" class="form-label required">City</label>
					<input autocomplete="off" required="required" class="form-control" id="txtCity" type="text" name="tx_mpqd_products[request][city]" value="" />
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-6">
				<div class="mb-3">
					<label for="selCountry" class="form-label required">Country</label>
					<select autocomplete="off" data-live-search="true" data-size="8" required="required" class="form-select form-control" id="selCountry" name="tx_mpqd_products[request][country]"><option value="">Please choose</option>
<option value="3">Afghanistan</option>
<option value="240">Åland</option>
<option value="6">Albania</option>
<option value="59">Algeria</option>
<option value="12">American Samoa</option>
<option value="1">Andorra</option>
<option value="9">Angola</option>
<option value="5">Anguilla</option>
<option value="10">Antarctica</option>
<option value="4">Antigua and Barbuda</option>
<option value="11">Argentina</option>
<option value="7">Armenia</option>
<option value="15">Aruba</option>
<option value="14">Australia</option>
<option value="13">Austria</option>
<option value="16">Azerbaijan</option>
<option value="23">Bahrain</option>
<option value="19">Bangladesh</option>
<option value="18">Barbados</option>
<option value="34">Belarus</option>
<option value="20">Belgium</option>
<option value="35">Belize</option>
<option value="25">Benin</option>
<option value="26">Bermuda</option>
<option value="31">Bhutan</option>
<option value="28">Bolivia</option>
<option value="249">Bonaire, Sint Eustatius and Saba</option>
<option value="17">Bosnia and Herzegovina</option>
<option value="33">Botswana</option>
<option value="32">Bouvet Island</option>
<option value="29">Brazil</option>
<option value="100">British Indian Ocean Territory</option>
<option value="226">British Virgin Islands</option>
<option value="27">Brunei</option>
<option value="22">Bulgaria</option>
<option value="21">Burkina Faso</option>
<option value="24">Burundi</option>
<option value="110">Cambodia</option>
<option value="45">Cameroon</option>
<option value="36">Canada</option>
<option value="50">Cape Verde</option>
<option value="117">Cayman Islands</option>
<option value="39">Central African Republic</option>
<option value="202">Chad</option>
<option value="44">Chile</option>
<option value="46">China</option>
<option value="51">Christmas Island</option>
<option value="37">Cocos (Keeling) Islands</option>
<option value="47">Colombia</option>
<option value="112">Comoros</option>
<option value="38">Congo</option>
<option value="40">Congo-Brazzaville</option>
<option value="43">Cook Islands</option>
<option value="48">Costa Rica</option>
<option value="42">Côte d’Ivoire</option>
<option value="93">Croatia</option>
<option value="49">Cuba</option>
<option value="250">Curaçao</option>
<option value="52">Cyprus</option>
<option value="53">Czech Republic</option>
<option value="56">Denmark</option>
<option value="55">Djibouti</option>
<option value="57">Dominica</option>
<option value="58">Dominican Republic</option>
<option value="60">Ecuador</option>
<option value="62">Egypt</option>
<option value="198">El Salvador</option>
<option value="84">Equatorial Guinea</option>
<option value="64">Eritrea</option>
<option value="61">Estonia</option>
<option value="200">Eswatini</option>
<option value="66">Ethiopia</option>
<option value="69">Falkland Islands</option>
<option value="71">Faroes</option>
<option value="68">Fiji</option>
<option value="67">Finland</option>
<option value="72">France</option>
<option value="77">French Guiana</option>
<option value="166">French Polynesia</option>
<option value="203">French Southern Territories</option>
<option value="73">Gabon</option>
<option value="81">Gambia</option>
<option value="76">Georgia</option>
<option value="54">Germany</option>
<option value="78">Ghana</option>
<option value="79">Gibraltar</option>
<option value="85">Greece</option>
<option value="80">Greenland</option>
<option value="75">Grenada</option>
<option value="83">Guadeloupe</option>
<option value="88">Guam</option>
<option value="87">Guatemala</option>
<option value="245">Guernsey</option>
<option value="82">Guinea</option>
<option value="89">Guinea-Bissau</option>
<option value="90">Guyana</option>
<option value="94">Haiti</option>
<option value="241">Heard Island and McDonald Islands</option>
<option value="92">Honduras</option>
<option value="91">Hong Kong SAR of China</option>
<option value="95">Hungary</option>
<option value="103">Iceland</option>
<option value="99">India</option>
<option value="96">Indonesia</option>
<option value="102">Iran</option>
<option value="101">Iraq</option>
<option value="97">Ireland</option>
<option value="246">Isle of Man</option>
<option value="98">Israel</option>
<option value="104">Italy</option>
<option value="105">Jamaica</option>
<option value="107">Japan</option>
<option value="244">Jersey</option>
<option value="106">Jordan</option>
<option value="118">Kazakhstan</option>
<option value="108">Kenya</option>
<option value="111">Kiribati</option>
<option value="253">Kosovo</option>
<option value="116">Kuwait</option>
<option value="109">Kyrgyzstan</option>
<option value="119">Laos</option>
<option value="128">Latvia</option>
<option value="120">Lebanon</option>
<option value="125">Lesotho</option>
<option value="124">Liberia</option>
<option value="129">Libya</option>
<option value="122">Liechtenstein</option>
<option value="126">Lithuania</option>
<option value="127">Luxembourg</option>
<option value="139">Macao SAR of China</option>
<option value="133">Madagascar</option>
<option value="147">Malawi</option>
<option value="149">Malaysia</option>
<option value="146">Maldives</option>
<option value="136">Mali</option>
<option value="144">Malta</option>
<option value="134">Marshall Islands</option>
<option value="141">Martinique</option>
<option value="142">Mauritania</option>
<option value="145">Mauritius</option>
<option value="233">Mayotte</option>
<option value="148">Mexico</option>
<option value="70">Micronesia</option>
<option value="132">Moldova</option>
<option value="131">Monaco</option>
<option value="138">Mongolia</option>
<option value="242">Montenegro</option>
<option value="143">Montserrat</option>
<option value="130">Morocco</option>
<option value="150">Mozambique</option>
<option value="137">Myanmar</option>
<option value="151">Namibia</option>
<option value="160">Nauru</option>
<option value="159">Nepal</option>
<option value="157">Netherlands</option>
<option value="152">New Caledonia</option>
<option value="162">New Zealand</option>
<option value="156">Nicaragua</option>
<option value="153">Niger</option>
<option value="155">Nigeria</option>
<option value="161">Niue</option>
<option value="154">Norfolk Island</option>
<option value="140">Northern Marianas</option>
<option value="114">North Korea</option>
<option value="135">North Macedonia</option>
<option value="158">Norway</option>
<option value="163">Oman</option>
<option value="169">Pakistan</option>
<option value="175">Palau</option>
<option value="238">Palestine</option>
<option value="164">Panama</option>
<option value="167">Papua New Guinea</option>
<option value="176">Paraguay</option>
<option value="165">Peru</option>
<option value="168">Philippines</option>
<option value="172">Pitcairn Islands</option>
<option value="170">Poland</option>
<option value="174">Portugal</option>
<option value="173">Puerto Rico</option>
<option value="177">Qatar</option>
<option value="178">Reunion</option>
<option value="179">Romania</option>
<option value="180">Russia</option>
<option value="181">Rwanda</option>
<option value="248">Saint Barthélemy</option>
<option value="188">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="113">Saint Kitts and Nevis</option>
<option value="121">Saint Lucia</option>
<option value="247">Saint Martin</option>
<option value="171">Saint Pierre and Miquelon</option>
<option value="224">Saint Vincent and the Grenadines</option>
<option value="231">Samoa</option>
<option value="193">San Marino</option>
<option value="197">São Tomé e Príncipe</option>
<option value="182">Saudi Arabia</option>
<option value="194">Senegal</option>
<option value="243">Serbia</option>
<option value="184">Seychelles</option>
<option value="192">Sierra Leone</option>
<option value="187">Singapore</option>
<option value="251">Sint Maarten</option>
<option value="191">Slovakia</option>
<option value="189">Slovenia</option>
<option value="183">Solomon Islands</option>
<option value="195">Somalia</option>
<option value="235">South Africa</option>
<option value="86">South Georgia and the South Sandwich Islands</option>
<option value="115">South Korea</option>
<option value="252">South Sudan</option>
<option value="65">Spain</option>
<option value="123">Sri Lanka</option>
<option value="185">Sudan</option>
<option value="196">Suriname</option>
<option value="190">Svalbard</option>
<option value="186">Sweden</option>
<option value="41">Switzerland</option>
<option value="199">Syria</option>
<option value="215">Taiwan</option>
<option value="206">Tajikistan</option>
<option value="216">Tanzania</option>
<option value="205">Thailand</option>
<option value="30">The Bahamas</option>
<option value="211">Timor-Leste</option>
<option value="204">Togo</option>
<option value="207">Tokelau</option>
<option value="210">Tonga</option>
<option value="213">Trinidad and Tobago</option>
<option value="209">Tunisia</option>
<option value="212">Türkiye</option>
<option value="208">Turkmenistan</option>
<option value="201">Turks and Caicos Islands</option>
<option value="214">Tuvalu</option>
<option value="218">Uganda</option>
<option value="217">Ukraine</option>
<option value="2">United Arab Emirates</option>
<option value="74">United Kingdom</option>
<option value="220">United States</option>
<option value="219">United States Minor Outlying Islands</option>
<option value="221">Uruguay</option>
<option value="227">US Virgin Islands</option>
<option value="222">Uzbekistan</option>
<option value="229">Vanuatu</option>
<option value="223">Vatican City</option>
<option value="225">Venezuela</option>
<option value="228">Vietnam</option>
<option value="230">Wallis and Futuna</option>
<option value="63">Western Sahara</option>
<option value="232">Yemen</option>
<option value="236">Zambia</option>
<option value="237">Zimbabwe</option>
</select>
				</div>
			</div>
		</div>

		<div class="row">
			<div class="col-md-12">
				<hr />
			</div>
		</div>

		<div class="row">
			<div class="col-md-12">
				<div class="mb-3">
					<label for="txtComments" class="form-label">Comments</label>
					<textarea autocomplete="off" class="form-control" id="txtComments" name="tx_mpqd_products[request][comments]"></textarea>
				</div>
			</div>
		</div>

		<div class="row marginTop15">
			<div class="col-md-12">
				<div id="alertContainer">
	<div class="alert alert-danger" role="alert" style="display:none;">
		<button type="button" class="close" data-dismiss="alert" aria-label="Close">
			<span aria-hidden="true">&times;</span>
		</button>

		<div class="content"></div>
	</div>

	<div class="alert alert-success" role="alert" style="display:none;">
		<button type="button" class="close" data-dismiss="alert" aria-label="Close">
			<span aria-hidden="true">&times;</span>
		</button>

		<div class="content"></div>
	</div>

	<div class="alert alert-warning" role="alert" style="display:none;">
		<button type="button" class="close" data-dismiss="alert" aria-label="Close">
			<span aria-hidden="true">&times;</span>
		</button>

		<div class="content"></div>
	</div>
</div>
			</div>
		</div>

		<div class="row mt-5 mb-5">

			<div class="col-md-12 text-right">
				<input class="btn btn-primary" type="submit" value="send request" />
			</div>
		</div>
	</form>
</div>

<script>
	$(document).ready(function(){
		$('#frmRequestProduct select:first').focus();
	});
</script>
