Untitled

<form class="crm-api-form">

<input name="contact-first" />
<input name="contact-surname" />
<input name="contact-company" />
<input name="contact-telephone" />
<input name="contact-email" />

<!-- when clicked open the modal --!>
<button type="button">Locate my connection</button>


<modal id="locate-my-connection-modal">
    <input type="checkbox" name="Please_select_the_requirements_for_your_business[]" value="SUPERFAST CONNECTION (up To 66Mbps)" />
    <input type="checkbox" name="Please_select_the_requirements_for_your_business[]" value="HYPERFAST CONNECTION (up To 300Mbps)" />
    <input type="checkbox" name="Please_select_the_requirements_for_your_business[]" value="BACK-UP CONNECTION (up To 24Mbps)" />
    <input type="checkbox" name="Please_select_the_requirements_for_your_business[]" value="SERVICE LEVEL AGREEMENT (5 Hour Fix Time)" />
    <input type="checkbox" name="Please_select_the_requirements_for_your_business[]" value="PHONE LINE (with Landline Number)" />
    <input type="checkbox" name="Please_select_the_requirements_for_your_business[]" value="DIVERSE ROUTING (dual Resiliency - 2 Exchanges)" />

    <input type="input" name="Please enter the 1st line of your address" />
    <input type="input" name="Please enter the address postcode" />
    <input type="input" name="Lastly, please enter your landline number" />

    <input type="submit" value="Submit Details" />
</modal>

</form>