| 85
| <![CDATA[<fieldset>
<section>
<label class="input">
<i class="icon-prepend fa fa-calendar"></i>
<input required type="date" id="data" name="data" placeholder="Data" value="2022-07-21">
</label>
</section>
<section>
<label class="input">
<i class="icon-prepend fa fa-globe"></i>
<input required type="text" id="nome_empresa" name="nome_empresa" placeholder="Nome da empresa">
</label>
</section>
<section>
<label class="input">
<i class="icon-prepend fa fa-map-marker"></i>
<input required type="text" id="endereco" name="endereco" placeholder="Endereço">
</label>
</section>
<div class="col-md-4 col-sm-4 nopadding">
<section>
<label class="input">
<input required type="text" id="municipio" name="municipio" placeholder="MunicÃpio">
</label>
</section>
</div>
<div class="col-md-4 col-sm-4 mobile-nopadding">
<section>
<label class="select">
<select name="estado" placeholder="Estado">
<option value="">Estado</option>
<option value="Acre">Acre</option>
<option value="Alagoas">Alagoas</option>
<option value="Amazonas">Amazonas</option>
<option value="Amapá">Amapá</option>
<option value="Bahia">Bahia</option>
<option value="Ceará">Ceará</option>
<option value="Distrito Federal">Distrito Federal</option>
<option value="Espirito Santo">Espirito Santo</option>
<option value="Goiás">Goiás</option>
<option value="Maranhão">Maranhão</option>
<option value="Mato Grosso do Sul">Mato Grosso do Sul</option>
<option value="Mato Grosso">Mato Grosso</option>
<option value="Minas Gerais">Minas Gerais</option>
<option value="Pará">Pará</option>
<option value="ParaÃba">ParaÃba</option>
<option value="Pernambuco">Pernambuco</option>
<option value="PiauÃ">PiauÃ</option>
<option value="Paraná">Paraná</option>
<option value="Rio de Janeiro">Rio de Janeiro</option>
<option value="Rio Grande do Norte">Rio Grande do Norte</option>
<option value="Rio Grande do Sul">Rio Grande do Sul</option>
<option value="Rondônia">Rondônia</option>
<option value="Roraima">Roraima</option>
<option value="Santa Catarina">Santa Catarina</option>
<option value="São Paulo">São Paulo</option>
<option value="Sergipe">Sergipe</option>
<option value="Tocantins">Tocantins</option>
</select>
<i></i>
</label>
</section>
</div>
<div class="col-md-4 col-sm-4 nopadding">
<section>
<label class="input">
<input required type="text" id="cep" name="cep" placeholder="CEP" onKeyDown="Mascara(this,Cep);" onKeyPress="Mascara(this,Cep);" onKeyUp="Mascara(this,Cep);">
</label>
</section>
</div>
<div class="col-md-6 col-sm-6 nopadding-left mobile-nopadding">
<section>
<label class="input">
<i class="icon-prepend fa fa-fax"></i>
<input required type="text" id="telefone" name="telefone" placeholder="Fone/FAX" onKeyDown="Mascara(this,mtel);" onKeyPress="Mascara(this,mtel);" onKeyUp="Mascara(this,mtel);" maxlength="15">
</label>
</section>
</div>
<div class="col-md-6 col-sm-6 nopadding-right mobile-nopadding">
<section>
<label class="input">
<i class="icon-prepend fa fa-envelope"></i>
<input required type="email" id="e_download" name="e_download" placeholder="E-mail">
</label>
</section>
</div>
<section>
<img src="/crqsc/portal/captcha/captcha.php?l=cbcc22324" alt="código captcha" class="no_100"/>
</section>
<section>
<label class="input">
<i class="icon-prepend fa fa-barcode"></i>
<input required type="text" name="captcha" id="captcha" value="" maxlength="100" placeholder="Digite o código acima">
</label>
</section>
</fieldset>]]>
|
