<!--includeForm-->

<link rel="stylesheet" type="text/css" href="http://iakovidislaw.com/t/images/css/formstyles.css" />

<div style="font-size:23px; margin: 0 0 15px;" >Оставьте ваши данные и мы свяжемся с Вам!</div>


<form method="post" class="form-inline">




 <div class="form-group">
	<label for="d[0]"  style="color:#000000;">Имя:</label><SPAN style="color:red"></SPAN>	    <br />
  <input class="contact-imput form-control" type="text" placeholder="Имя" size="35" maxlength="75" value="" name="d[0]" id="d[0]" />
</div>


 <div class="form-group">
	<label for="d[1]"  style="color:#000000;">E-mail:</label><SPAN style="color:red"></SPAN>	    <br />
  <input class="contact-imput form-control" type="text" placeholder="E-mail" size="35" maxlength="75" value="" name="d[1]" id="d[1]" />
</div>


 <div class="form-group">
	<label for="d[2]"  style="color:#000000;">Телефон:</label>	    <br />
  <input class="contact-imput form-control" type="text" placeholder="Телефон" size="35" maxlength="75" value="" name="d[2]" id="d[2]" />
</div>
<input class="form-button" type="submit" value="Отправить">
<re-captcha data-captcha="recaptcha"
     data-name="captcha"
     data-sitekey="6LfLhZ0UAAAAAEB4sGlu_2uKR2xqUQpOMdxygQnA"
     data-lang="ru"
     data-rsize="invisible"
     data-type="image"
     data-theme="light"></re-captcha></form>

<script src="/shared/misc/calendar.gen.js" type="text/javascript" language="javascript" charset="utf-8"></script>
<!--includeForm-->
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