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<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>
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