<!DOCTYPE html>
<html lang="en">
<head>
<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">
<script src="https://www.google.com/recaptcha/api.js"></script>
<script>
function timestamp() { var response = document.getElementById("g-recaptcha-response"); if (response == null || response.value.trim() == "") {var elems = JSON.parse(document.getElementsByName("captcha_settings")[0].value);elems["ts"] = JSON.stringify(new Date().getTime());document.getElementsByName("captcha_settings")[0].value = JSON.stringify(elems); } } setInterval(timestamp, 500);
</script>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Contact Us</title>
<style>
body {
font-family: Arial, sans-serif;
background-color: #f4f4f4;
margin: 0;
padding: 20px;
}
.form-container {
max-width: 400px;
background: #fff;
padding: 15px;
margin: auto;
border-radius: 8px;
box-shadow: 0px 4px 6px rgba(0, 0, 0, 0.1);
}
h2 {
text-align: center;
color: #004c97;
font-size: 20px;
margin-bottom: 10px;
}
.form-row {
display: flex;
gap: 10px;
}
.form-row div {
flex: 1;
}
label {
font-weight: bold;
display: block;
font-size: 14px;
margin-bottom: 3px;
}
input, select, textarea {
width: 100%;
padding: 8px;
border: 1px solid #ccc;
border-radius: 4px;
font-size: 14px;
}
textarea {
resize: vertical;
min-height: 50px;
}
.submit-btn {
background-color: #004c97;
color: white;
font-size: 16px;
border: none;
padding: 10px;
margin-top: 5px;
cursor: pointer;
width: 100%;
border-radius: 4px;
transition: background 0.3s;
}
.submit-btn:hover {
background-color: #003366;
}
@media (max-width: 480px) {
.form-row {
flex-direction: column;
}
}
</style>
</head>
<body>
<div class="form-container">
<h2>Contact Us</h2>
<form action="https://webto.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8&orgId=00DHp00000Avgkr" method="POST">
<input type=hidden name='captcha_settings' value='{"keyname":"Great","fallback":"true","orgId":"00DHp00000Avgkr","ts":""}'>
<input type="hidden" name="oid" value="00DHp00000Avgkr">
<input type="hidden" name="retURL" value="https://greatroofing.com/">
<input type="hidden" name="lead_source" value="Website">
<input type="hidden" name="00NHp00001bW9St" value="Great Roofing">
<input type="hidden" name="country_code" value="US">
<div class="form-row">
<div>
<label for="first_name">First Name</label>
<input id="first_name" name="first_name" type="text" required>
</div>
<div>
<label for="last_name">Last Name</label>
<input id="last_name" name="last_name" type="text" required>
</div>
</div>
<label for="email">Email</label>
<input id="email" name="email" type="email" required>
<label for="phone">Phone</label>
<input id="phone" name="phone" type="tel">
<label for="street">Street</label>
<input id="street" name="street" type="text">
<div class="form-row">
<div>
<label for="city">City</label>
<input id="city" name="city" type="text">
</div>
<div>
<label for="state_code">State</label>
<select id="state_code" name="state_code">
<option value="">-- Select --</option>
<option value="OH">Ohio</option>
<option value="CO">Colorado</option>
<option value="KY">Kentucky</option>
<option value="IN">Indiana</option>
<option value="MI">Michigan</option>
</select>
</div>
<div>
<label for="zip">Zip Code</label>
<input id="zip" name="zip" type="text">
</div>
</div>
<label for="00NHp00001bWjNk">How did you hear about us?</label>
<input id="00NHp00001bWjNk" name="00NHp00001bWjNk" type="text">
<label for="00NHp00001bWDiU">Message</label>
<textarea id="00NHp00001bWDiU" name="00NHp00001bWDiU"></textarea>
<div class="g-recaptcha" data-sitekey="6Lf4pAUrAAAAAIacJ1YTzU4jWlyusSqY_oB6dxZ_"></div><br>
<input type="submit" class="submit-btn" value="Submit">
</form>
</div>
</body>
</html>
