&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; <b><u>..::SİPARİŞ FORMU::..</b></u>


 <!-- ContactForm 1.5 by planetluc.com START -->

<form name="form1" method="post" action="">
<table  border="0" cellpadding="1" cellspacing="0">
<tr><td class="text">Firma/Unvan&nbsp;</td>
<td class="field"><input type="text" name="company" value="" class="inputLine" style="width:300px;" /></td></tr>
<tr><td class="text">Ad Soyad*&nbsp;</td>
<td class="field"><input type="text" name="name" value="" class="inputLine" style="width:300px;" /></td></tr>
<tr><td class="text">Adres&nbsp;</td>
<td class="field"><input type="text" name="address" value="" class="inputLine" style="width:300px;" /></td></tr>
<tr><td class="text">Şehir*&nbsp;</td>
<td class="field"><input type="text" name="city" value="" class="inputLine" style="width:300px;" /></td></tr>
<tr><td class="text">Telefon*&nbsp;</td>
<td class="field"><input type="text" name="phone" value="" class="inputLine" style="width:300px;" /></td></tr>
<tr><td class="text">Email*&nbsp;</td>
<td class="field"><input type="text" name="email" value="" class="inputLine" style="width:300px;" /></td></tr>
<tr><td class="text">Karşı yanıt*&nbsp;</td>
<td class="field"><input type="radio" name="replyby" value="email" style="vertical-align:middle;" id="replyby1" /> <label for="replyby1">Email</label>&nbsp;&nbsp;<input type="radio" name="replyby" value="telefon" style="vertical-align:middle;" id="replyby2" /> <label for="replyby2">Telefon</label>&nbsp;&nbsp;<input type="radio" name="replyby" value="posta" style="vertical-align:middle;" id="replyby3" /> <label for="replyby3">Posta</label>&nbsp;&nbsp;</td></tr>
<tr><td class="text">Sipariş*&nbsp;</td>
<td class="field">
<select name="income" style="width:300px;">
<option value="" selected="selected">-- siparis konusu seçiniz --</option>
<option value="WebT" >Web Tasarim</option>
<option value="LogoT" >Logo</option>
<option value="BannerT" >Banner</option>
<option value="KampanyaT" >Kampanya </option>
</select>
</td></tr>
<tr><td class="text" colspan="2"><hr /></td></td></tr>
<tr><td class="text">Paket*&nbsp;</td>
<td class="field"><input type="checkbox" name="interests[1]" value="Soke1" style="vertical-align:middle;" id="interests1" /> <label for="interests1">Soke1</label>&nbsp;&nbsp;<input type="checkbox" name="interests[2]" value="Soke2" style="vertical-align:middle;" id="interests2" /> <label for="interests2">Soke2</label>&nbsp;&nbsp;<input type="checkbox" name="interests[3]" value="Soke3" style="vertical-align:middle;" id="interests3" /> <label for="interests3">Soke3</label>&nbsp;&nbsp;<input type="checkbox" name="interests[4]" value="Diger" style="vertical-align:middle;" id="interests4" /> <label for="interests4">Diger</label>&nbsp;&nbsp;</td></tr>
<tr><td class="text">Icerik*&nbsp;</td>
<td class="field">
<select name="interests_2[]" multiple style="width:300px;">
<option value="Kurumsal" >Kurumsal</option>
<option value="Kisisel" >Kisisel</option>
<option value="Haber" >Haber</option>
<option value="Diger" >Diger</option>
</select>
</td></tr>
<tr><td class="text" colspan="2"><hr /></td></td></tr>
<tr><td class="text">Başlık*&nbsp;</td>
<td class="field"><textarea name="request" id="cf_request" class="inputField" style="width:300px; height:60px;"  ></textarea>
</td></tr>
<tr><td class="text">Açıklama*&nbsp;</td>
<td class="field"><textarea name="limited" id="cf_limited" class="inputField" style="width:300px; height:60px;" onkeydown="cfCount('cf_limited', 'cf_remchars_limited', 250)" onkeyup="cfCount('cf_limited', 'cf_remchars_limited', 250)" ></textarea>
<SCRIPT LANGUAGE='JavaScript'>
<!-- Begin
function cfGetElement(id){
if (document.getElementById){
return document.getElementById(id);
}else if (document.all){
return document.all.id;
}
}

function cfCount(field, cntfield, maxlimit) {
var source = cfGetElement(field); count = cfGetElement(cntfield); 
if (source.value.length > maxlimit) 
source.value = source.value.substring(0, maxlimit);
else
count.innerHTML = maxlimit - source.value.length;
}
//  End -->
</script>
<br />Kalan Karakter sayısı: <span id="cf_remchars_limited">250</span></td></tr>
<tr><td class="text"> &nbsp; </td><td align="right" class="text">* Doldurulması Zorunlu</td></tr>
<tr><td class="text">&nbsp;</td><td  class="field"><input name="Submit" type="Submit" class="inputButton" style="width:300px;" value="Gönder">
<input name="do" type="hidden" id="do" value="send"></td>
</tr></table>
</form>

 <!-- ContactForm 1.5 by planetluc.com END -->


</body> 
</html>