@props(['referrer'])
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Strict data protection, your data will not be shared.

*Required fields are marked with an asterisk ‘*’

{!! Form::open([ 'url' => 'api/lead', 'id' => 'lead', 'class' => 'ajaxform', 'data-endpoint' => 'lead']) !!} {!! Form::hidden('referrer', $referrer) !!} {!! Form::hidden('id', null, ['id' => 'lead_id']) !!} @if(!empty(auth()->user())) {!! Form::hidden('user_id', auth()->user()->id, ['id' => 'user_id']) !!} @endif {!! Form::hidden('package_id', null, ['id' => 'lead_form_package_id']) !!}
{!! Form::text('adr[address_line_1]', null, [ 'placeholder' => '*1st line of address', 'class' => 'form-control', 'maxlength' => 240]) !!}
{!! Form::text('adr[address_line_2]', null, [ 'placeholder' => '2nd line of address', 'class' => 'form-control', 'maxlength' => 240]) !!}
{!! Form::text('adr[address_line_3]', null, [ 'placeholder' => '3rd line of address', 'class' => 'form-control', 'maxlength' => 240]) !!}
{!! Form::text('adr[city]', null, [ 'placeholder' => '*City / Town', 'class' => 'form-control', 'id' => 'adr_city', 'maxlength' => 120]) !!}
{!! Form::text('adr[county]', null, [ 'placeholder' => 'County / Region', 'class' => 'form-control', 'id' => 'adr_county', 'maxlength' => 120]) !!}
{!! Form::text('adr[postcode]', null, [ 'placeholder' => '*Postcode', 'class' => 'form-control', 'id' => 'adr_postcode', 'maxlength' => 12]) !!}
{!! Form::text('fullname', null, [ 'placeholder' => '*Full name', 'class' => 'form-control', 'maxlength' => 240]) !!}
{!! Form::text('adr[telephone]', null, [ 'placeholder' => '*Contact phone number', 'id' => 'lf_tel', 'class' => 'form-control', 'maxlength' => 22]) !!}
@if(empty(auth()->user()))
{!! Form::email('adr[email]', null, [ 'placeholder' => '*Email', 'class' => 'form-control', 'autocomplete' => 'email', 'maxlength' => 120]) !!}
{!! Form::email('cemail', null, [ 'placeholder' => '*Confirm email', 'class' => 'form-control', 'autocomplete' => 'email', 'maxlength' => 120]) !!}
@endif
Address type:   {!! Form::select('adr[type]', array_slice(config('enum.address_types'), 0, 3), 0, ['id' => 'type-select']) !!}
@if(empty(auth()->user()))
@endif
{!! Form::checkbox('contact_consent', 1, false, ['id' => 'contact_consent', 'class' => 'p-0']) !!}
{!! Form::label('contact_consent', ' Confirm you give consent for us to contact you with updates about our internet service in your area.') !!}
{!! Form::close() !!}
Address added to our list.

Confirmation has been sent to your email address along with more specific information.

Connect your community
Our referral program can lower the cost of your service. Please share the news using your preferred social network below.
@if(!empty(auth()->user())) @endif