<?php
use PHPMailer\PHPMailer\PHPMailer;
require 'PHPMailer.php';
require 'SMTP.php';
function ValidateEmail($email)
{
$pattern = '/^([0-9a-z]([-.\w]*[0-9a-z])*@(([0-9a-z])+([-\w]*[0-9a-z])*\.)+[a-z]{2,6})$/i';
return preg_match($pattern, $email);
}
function ReplaceVariables($code)
{
foreach ($_POST as $key => $value)
{
if (is_array($value))
{
$value = implode(",", $value);
}
$name = "$" . $key;
$code = str_replace($name, $value, $code);
}
$code = str_replace('
$ipaddress', $_SERVER['REMOTE_ADDR'], $code);
return $code;
}
if ($_SERVER['REQUEST_METHOD'] == 'POST' && isset($_POST['formid']) && $_POST['formid'] == 'work_afspraak')
{
$mailto = '
vomr@skynet.be';
$mailfrom = isset($_POST['email']) ? $_POST['email'] : $mailto;
$subject = 'Website form';
$message = '<font style="color:#000000;font-family:arial;font-size:27px"><strong>WORK-AFSPRAAK</strong></font><font style="color:#000000;font-family:arial;font-size:16px"> via ALL-RIDE website<br><br>Naam: <strong>$naam<br></strong>NummerPlaat: <strong>$nummerplaat<br></strong>Telefoon: <strong>$tel<br></strong>E-mail: <strong>$email<br></strong><br>Chassis Nummer: </font><font style="color:#FF0000;font-family:arial;font-size:20px"><strong>$chassis<br></strong></font><font style="color:#000000;font-family:arial;font-size:16px">Merk: </font><font style="color:#000000;font-family:arial;font-size:20px"> <strong>$merk<br></strong></font><font style="color:#000000;font-family:arial;font-size:16px">Model: </font><font style="color:#000000;font-family:arial;font-size:20px"> <strong>$model<br></strong></font><font style="color:#000000;font-family:arial;font-size:16px">Kleur: <strong> </strong></font><font style="color:#000000;font-family:arial;font-size:20px"><strong>$kleur<br></strong></font><font style="color:#000000;font-family:arial;font-size:16px"><strong><br></strong><br>Afspraak datum: <strong>$datum </strong>Van:<strong> $uur_begin </strong>terug:<strong> $uur_terug<br></strong><br>Ophalen: </font><font style="color:#000000;font-family:arial;font-size:20px"><strong>$bedrijf</strong><br></font><font style="color:#000000;font-family:arial;font-size:16px"> <strong> </strong></font><font style="color:#000000;font-family:arial;font-size:20px"><strong>$straat<br></strong></font><font style="color:#000000;font-family:arial;font-size:16px"> <strong> </strong></font><font style="color:#000000;font-family:arial;font-size:20px"><strong>$plaats<br></strong></font><font style="color:#000000;font-family:arial;font-size:16px"><br>Uit te voeren werken: <br><br><strong>$geen_onderhoud</strong><br><strong>$geen_remmen</strong><br><strong>$geen_remmen<
/strong><br><strong>$geen_keuring<br>$geen_andere</strong><i> (zie opmerkigen) </i><br><br><br><br>Opmerking:<br><strong>$opmerking</strong><br><br></font>';
$success_url = './work_succes.html';
$error_url = './work_error.html';
$error = '';
$autoresponder_from = '
no_replie@allride.be';
$autoresponder_to = isset($_POST['email']) ? $_POST['email'] : $mailfrom;
$autoresponder_subject = 'Uw aanvraag tot afspraak bij ALLRIDE Gar VAN OLMEN';
$autoresponder_message = '<font style="color:#000000;font-family:arial;font-size:16px">Beste Mvr/Mr <strong>$naam<br></strong><br>We hebben uw aanvraag via onze website goed ontvangen.<br><br>U maakte een afspraak voor voertuig:<br><strong>$merk $model </strong>met de kleur:<strong> $kleur<br>Chassis: $chassis<br><br></strong>U wil dat wij dit voertuig op halen op onderstaand adres:<br><strong>$bedrijf<br>$straat<br>$plaats<br><br></strong>U koos om volgende werken uit te laten voeren:<strong><br>$geen_onderhoud<br>$geen_remmen<br>$geen_banden<br>$geen_keuring<br>$geen_andere</strong><i> (zie opmerkingen)</i><strong><br><br></strong>U voegde volgende opmerkingen toe:<strong><br>$opmerking<br></strong><br>Uw aanvraag was voor datum <strong>$datum </strong>Van:<strong> $uur_begin </strong>uur, tot<strong> $uur_terug</strong> uur.<br><br>Deze afspraak en datum zijn pas geldig nadat U een bevestiging hierover van Gar. ALLRIDE hebt ontvangen.<br>Dit kan gebeuren of via uw e-mail adres <strong>$email</strong> , of via telefoon<strong> $tel </strong>. <br>Wij zullen U zo spoedig mogelijk hierover contacteren. <br><br>Met vriendelijke groeten,<br> ALLRIDE <br>Gar. VAN OLMEN Team. <br><br>Alvast dank voor het gebruiken van onze website.<br><br>PS. </font><font style="color:#4169E1;font-family:arial;font-size:16px"><i>Gebruik dit e-mail adres (
no_replie@allride.be) </i><strong>niet </strong><i>om ons te contacteren, <br>dit adres wordt niet verwerkt door onze server. </i></font>';
$eol = "\n";
$mail = new PHPMailer();
$mail->IsSendmail();
$subject = ReplaceVariables($subject);
$mail->Subject = stripslashes($subject);
$mail->From = $mailfrom;
$mail->FromName = $mailfrom;
$mailto_array = explode(",", $mailto);
for ($i = 0; $i < count($mailto_array); $i++)
{
if(trim($mailto_array[$i]) != "")
{
$mail->AddAddress($mailto_array[$i], "");
}
}
$mail->AddReplyTo($mailfrom);
if (!ValidateEmail($mailfrom))
{
$error .= "The specified email address is invalid!\n<br>";
}
if (!empty($error))
{
$errorcode = file_get_contents($error_url);
$replace = "##error##";
$errorcode = str_replace($replace, $error, $errorcode);
echo $errorcode;
exit;
}
$mail->CharSet = 'ISO-8859-1';
if (!empty($_FILES))
{
foreach ($_FILES as $key => $value)
{
if ($_FILES[$key]['error'] == 0)
{
$mail->AddAttachment($_FILES[$key]['tmp_name'], $_FILES[$key]['name']);
}
}
}
$message = ReplaceVariables($message);
$message = stripslashes($message);
$mail->MsgHTML($message);
$mail->IsHTML(true);
if (!$mail->Send())
{
die('PHPMailer error: ' . $mail->ErrorInfo);
}
$mail->ClearAddresses();
$mail->ClearAttachments();
$autoresponder_subject = ReplaceVariables($autoresponder_subject);
$mail->Subject = stripslashes($autoresponder_subject);
$mail->From = $autoresponder_from;
$mail->FromName = $autoresponder_from;
$mail->AddAddress($autoresponder_to, "");
$mail->AddReplyTo($autoresponder_from);
$autoresponder_message = ReplaceVariables($autoresponder_message);
$autoresponder_message = stripslashes($autoresponder_message);
$mail->MsgHTML($autoresponder_message);
$mail->IsHTML(true);
if (!$mail->Send())
{
die('PHPMailer error: ' . $mail->ErrorInfo);
}
header('Location: '.$success_url);
exit;
}
?>
<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>AFSPRAAK MAKEN</title>
<meta name="description" content="Garage VAN OLMEN bij PCA">
<meta name="keywords" content="garage; gibphoto; vanolmen; van olmen; allride; garage van olmen; garagevanolmen: onderhoud; tweedehands; occasies; pca; citroen; peugeot; citroen herentals; peugeot herentals; herentals; garage herentals">
<meta name="author" content="GiBphoto">
<meta name="generator" content="GiBphoto">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link href="allride_icon.ico" rel="shortcut icon" type="image/x-icon">
<link href="allride02v14(64bit).css" rel="stylesheet">
<link href="work_afspraak2.css" rel="stylesheet">
<script src="jquery-1.12.4.min.js"></script>
<script>
function Validatework_afspraak()
{
var regexp;
var naam = document.getElementById('naam');
if (!(naam.disabled || naam.style.display === 'none' || naam.style.visibility === 'hidden'))
{
if (naam.value == "")
{
alert("Please enter a value for the \"naam\" field.");
naam.focus();
return false;
}
}
var nummerpl = document.getElementById('nummerpl');
if (!(nummerpl.disabled || nummerpl.style.display === 'none' || nummerpl.style.visibility === 'hidden'))
{
if (nummerpl.value == "")
{
alert("Please enter a value for the \"nummerplaat\" field.");
nummerpl.focus();
return false;
}
}
var tel = document.getElementById('tel');
if (!(tel.disabled || tel.style.display === 'none' || tel.style.visibility === 'hidden'))
{
if (tel.value == "")
{
alert("Please enter a value for the \"tel\" field.");
tel.focus();
return false;
}
}
var email = document.getElementById('email');
if (!(email.disabled || email.style.display === 'none' || email.style.visibility === 'hidden'))
{
if (email.value == "")
{
alert("Voer een geldig E-mail adres in");
email.focus();
return false;
}
}
var datum = document.getElementById('datum');
if (!(datum.disabled || datum.style.display === 'none' || datum.style.visibility === 'hidden'))
{
if (datum.value == "")
{
alert("Please enter a value for the \"datum\" field.");
datum.focus();
return false;
}
}
var merk = document.getElementById('merk');
if (!(merk.disabled ||
merk.style.display === 'none' ||
merk.style.visibility === 'hidden'))
{
if (merk.selectedIndex == 0)
{
alert("Maak een keuze");
merk.focus();
return false;
}
}
var model = document.getElementById('model');
if (!(model.disabled || model.style.display === 'none' || model.style.visibility === 'hidden'))
{
if (model.value == "")
{
alert("Please enter a value for the \"model\" field.");
model.focus();
return false;
}
}
var bedrijf = document.getElementById('bedrijf');
if (!(bedrijf.disabled || bedrijf.style.display === 'none' || bedrijf.style.visibility === 'hidden'))
{
if (bedrijf.value == "")
{
alert("Please enter a value for the \"bedrijf\" field.");
bedrijf.focus();
return false;
}
}
var plaats = document.getElementById('plaats');
if (!(plaats.disabled || plaats.style.display === 'none' || plaats.style.visibility === 'hidden'))
{
if (plaats.value == "")
{
alert("Please enter a value for the \"plaats\" field.");
plaats.focus();
return false;
}
}
var straat = document.getElementById('straat');
if (!(straat.disabled || straat.style.display === 'none' || straat.style.visibility === 'hidden'))
{
if (straat.value == "")
{
alert("Please enter a value for the \"straat\" field.");
straat.focus();
return false;
}
}
var kleur = document.getElementById('kleur');
if (!(kleur.disabled || kleur.style.display === 'none' || kleur.style.visibility === 'hidden'))
{
if (kleur.value == "")
{
alert("Please enter a value for the \"kleur\" field.");
kleur.focus();
return false;
}
}
var uur_begin = document.getElementById('uur_begin');
if (!(uur_begin.disabled || uur_begin.style.display === 'none' || uur_begin.style.visibility === 'hidden'))
{
if (uur_begin.value == "")
{
alert("Please enter a value for the \"uur_begin\" field.");
uur_begin.focus();
return false;
}
}
var uur_terug = document.getElementById('uur_terug');
if (!(uur_terug.disabled || uur_terug.style.display === 'none' || uur_terug.style.visibility === 'hidden'))
{
if (uur_terug.value == "")
{
alert("Please enter a value for the \"uur_terug\" field.");
uur_terug.focus();
return false;
}
}
return true;
}
</script>
<script src="wwb14.min.js"></script>
<script>
$(document).ready(function()
{
$("#email").change(function()
{
if ($('#email').val().length == 0)
{
ShowObject('label_behandeling1', 0);
ShowObject('label_behandeling2', 0);
ShowObject('label_chassis', 0);
ShowObject('chassis', 0);
ShowObject('label_merk', 0);
ShowObject('merk', 0);
ShowObject('label_model', 0);
ShowObject('model', 0);
ShowObject('label_kleur', 0);
ShowObject('kleur', 0);
ShowObject('label_ja', 0);
ShowObject('wb_radiob_ja', 0);
ShowObject('label_nee', 0);
ShowObject('wb_radiob_nee', 0);
ShowObject('label_gevr_werken', 0);
ShowObject('wb_check_onderhoud', 0);
ShowObject('label_onderhoud', 0);
ShowObject('wb_check_banden', 0);
ShowObject('label_banden', 0);
ShowObject('wb_check_keuring', 0);
ShowObject('label_keuring', 0);
ShowObject('wb_check_remmen', 0);
ShowObject('label_remmen', 0);
ShowObject('wb_check_andere', 0);
ShowObject('label_andere', 0);
ShowObject('wb_text_andere', 0);
}
if ($('#email').val().length != 0)
{
ShowObject('label_behandeling1', 1);
ShowObject('label_behandeling2', 1);
ShowObject('label_ja', 1);
ShowObject('wb_radiob_ja', 1);
ShowObject('label_nee', 1);
ShowObject('wb_radiob_nee', 1);
}
});
$("#email").trigger('change');
$("#datum").change(function()
{
if ($('#datum').val().length == 0)
{
ShowObject('label_begin', 0);
ShowObject('uur_begin', 0);
ShowObject('label_terug', 0);
ShowObject('uur_terug', 0);
}
if ($('#datum').val().length != 0)
{
ShowObject('label_begin', 1);
ShowObject('uur_begin', 1);
ShowObject('wb_tekst_locatieuur', 1);
ShowObject('label_terug', 1);
ShowObject('uur_terug', 1);
}
});
$("#datum").trigger('change');
$("#chassis").change(function()
{
if ($('#chassis').val().length == 0)
{
ShowObject('label_merk', 0);
ShowObject('merk', 0);
ShowObject('label_model', 0);
ShowObject('model', 0);
ShowObject('label_kleur', 0);
ShowObject('kleur', 0);
}
if ($('#chassis').val().length != 0)
{
ShowObject('label_merk', 1);
ShowObject('merk', 1);
ShowObject('label_model', 1);
ShowObject('model', 1);
ShowObject('label_kleur', 1);
ShowObject('kleur', 1);
}
});
$("#chassis").trigger('change');
$("#bedrijf").change(function()
{
if ($('#bedrijf').val().length == 0)
{
ShowObject('label_merk', 0);
}
});
$("#bedrijf").trigger('change');
$("#plaats").change(function()
{
if ($('#plaats').val().length != 0)
{
ShowObject('label_omschr', 1);
ShowObject('opmerking', 1);
ShowObject('label_datum', 1);
ShowObject('datum', 1);
ShowObject('wb_tekst_weekvoorhand', 1);
ShowObject('label_gevr_werken', 1);
ShowObject('wb_check_onderhoud', 1);
ShowObject('label_onderhoud', 1);
ShowObject('wb_check_banden', 1);
ShowObject('label_banden', 1);
ShowObject('wb_check_remmen', 1);
ShowObject('label_remmen', 1);
ShowObject('wb_check_keuring', 1);
ShowObject('label_keuring', 1);
ShowObject('wb_check_andere', 1);
ShowObject('label_andere', 1);
ShowObject('wb_text_andere', 1);
}
});
$("#plaats").trigger('change');
$("#uur_terug").change(function()
{
if ($('#uur_terug').val().length == 0)
{
ShowObject('but_verzenden', 0);
}
if ($('#uur_terug').val().length != 0)
{
ShowObject('but_verzenden', 1);
}
});
$("#uur_terug").trigger('change');
$("#kleur").change(function()
{
if ($('#kleur').val().length == 0)
{
ShowObject('wb_tekst_adresinvoer', 0);
ShowObject('label_bedrijf', 0);
ShowObject('bedrijf', 0);
ShowObject('label_straat', 0);
ShowObject('straat', 0);
ShowObject('label_plaats', 0);
ShowObject('plaats', 0);
ShowObject('label_omschr', 0);
ShowObject('opmerking', 0);
ShowObject('label_datum', 0);
ShowObject('datum', 0);
ShowObject('wb_tekst_weekvoorhand', 0);
ShowObject('wb_tekst_locatieuur', 0);
ShowObject('label_begin', 0);
ShowObject('uur_begin', 0);
ShowObject('label_terug', 0);
ShowObject('uur_terug', 0);
ShowObject('but_verzenden', 0);
}
if ($('#kleur').val().length != 0)
{
ShowObject('wb_tekst_adresinvoer', 1);
ShowObject('label_bedrijf', 1);
ShowObject('bedrijf', 1);
ShowObject('label_straat', 1);
ShowObject('straat', 1);
ShowObject('label_plaats', 1);
ShowObject('plaats', 1);
}
});
$("#kleur").trigger('change');
$("#radiob_ja").change(function()
{
if ($('#radiob_ja').is(':checked'))
{
ShowObject('label_merk', 1);
ShowObject('merk', 1);
ShowObject('label_model', 1);
ShowObject('model', 1);
ShowObject('label_kleur', 1);
ShowObject('kleur', 1);
ShowObject('label_chassis', 0);
ShowObject('chassis', 0);
}
if (!$('#radiob_ja').is(':checked'))
{
ShowObject('label_merk', 0);
ShowObject('merk', 0);
ShowObject('label_model', 0);
ShowObject('model', 0);
ShowObject('label_kleur', 0);
ShowObject('kleur', 0);
}
});
$("#radiob_ja").trigger('change');
$("#radiob_nee").change(function()
{
if ($('#radiob_nee').is(':checked'))
{
ShowObject('label_chassis', 1);
ShowObject('chassis', 1);
ShowObject('label_merk', 0);
ShowObject('merk', 0);
ShowObject('label_model', 0);
ShowObject('model', 0);
ShowObject('label_kleur', 0);
ShowObject('kleur', 0);
}
if (!$('#radiob_nee').is(':checked'))
{
ShowObject('label_chassis', 0);
}
});
$("#radiob_nee").trigger('change');
});
</script>
</head>
<body>
<div id="container">
<div id="wb_page1Shape1">
<a href="./index.html"><img src="images/work_afspraak2_0019.png" id="page1Shape1" alt=""></a></div>
<div id="wb_work_afspraak">
<form name="work_afspraak" method="post" action="<?php echo basename(__FILE__); ?>" enctype="multipart/form-data" id="work_afspraak" onsubmit="return Validatework_afspraak()">
<input type="hidden" name="formid" value="work_afspraak">
<input type="text" id="naam" name="naam" value="" tabindex="1" spellcheck="false">
<label for="" id="label_nummerpl">NummerPlaat:</label>
<input type="text" id="nummerpl" name="nummerplaat" value="" tabindex="2" spellcheck="false">
<input type="text" id="tel" name="tel" value="" tabindex="3" spellcheck="false">
<label for="" id="label_tel">Tel / GSM:</label>
<input type="email" id="email" name="email" value="" tabindex="4" spellcheck="false">
<label for="" id="label_email">Email:</label>
<label for="opmerking" id="label_omschr">Opmerking</label>
<input type="date" id="datum" name="datum" value="" tabindex="14" spellcheck="false">
<label for="datum" id="label_datum">Datum:</label>
<label for="" id="label_titel">WORK-ALLRIDE afspraak</label>
<textarea name="opmerking" id="opmerking" rows="5" cols="40" tabindex="13" spellcheck="false"></textarea>
<label for="" id="label_naam">Naam:</label>
<input type="text" id="chassis" name="chassis" value="" tabindex="6" spellcheck="false">
<select name="merk" size="1" id="merk" tabindex="7">
<option selected value="Kies">Kies</option>
<option value="Abarth">Abarth</option>
<option value="AC">AC</option>
<option value="Acura">Acura</option>
<option value="Aixam">Aixam</option>
<option value="Alfa Romeo">Alfa Romeo</option>
<option value="Alpina">Alpina</option>
<option value="Artega">Artega</option>
<option value="Asia Motors">Asia Motors</option>
<option value="Aston Martin">Aston Martin</option>
<option value="Audi">Audi</option>
<option value="Austin">Austin</option>
<option value="Bentley">Bentley</option>
<option value="BMW">BMW</option>
<option value="Borgward">Borgward</option>
<option value="Brilliance">Brilliance</option>
<option value="Bugatti">Bugatti</option>
<option value="Buick">Buick</option>
<option value="Cadillac">Cadillac</option>
<option value="Casalini">Casalini</option>
<option value="Caterham">Caterham</option>
<option value="Chatenet">Chatenet</option>
<option value="Chevrolet">Chevrolet</option>
<option value="Chrysler">Chrysler</option>
<option value="Citroen">Citroen</option>
<option value="Cobra">Cobra</option>
<option value="Corvette">Corvette</option>
<option value="Dacia">Dacia</option>
<option value="Daewoo">Daewoo</option>
<option value="Daihatsu">Daihatsu</option>
<option value="DeTomaso">DeTomaso</option>
<option value="Dodge">Dodge</option>
<option value="Donkervoort">Donkervoort</option>
<option value="DS">DS</option>
<option value="Ferrari">Ferrari</option>
<option value="Fiat">Fiat</option>
<option value="Fisker">Fisker</option>
<option value="Ford">Ford</option>
<option value="GAC Gonow">GAC Gonow</option>
<option value="Gemballa">Gemballa</option>
<option value="GMC">GMC</option>
<option value="Grecav">Grecav</option>
<option value="Hamann">Hamann</option>
<option value="Holden">Holden</option>
<option value="Honda">Honda</option>
<option value="Hummer">Hummer</option>
<option value="Hyundai">Hyundai</option>
<option value="Infiniti">Infiniti</option>
<option value="Isuzu">Isuzu</option>
<option value="Iveco">Iveco</option>
<option value="Jaguar">Jaguar</option>
<option value="Jeep">Jeep</option>
<option value="Kia">Kia</option>
<option value="Koenigsegg">Koenigsegg</option>
<option value="KTM">KTM</option>
<option value="Lada">Lada</option>
<option value="Lamborghini">Lamborghini</option>
<option value="Lancia">Lancia</option>
<option value="Land Rover">Land Rover</option>
<option value="Landwind">Landwind</option>
<option value="Lexus">Lexus</option>
<option value="Ligier">Ligier</option>
<option value="Lincoln">Lincoln</option>
<option value="Lotus">Lotus</option>
<option value="Mahindra">Mahindra</option>
<option value="Maserati">Maserati</option>
<option value="Maybach">Maybach</option>
<option value="Mazda">Mazda</option>
<option value="McLaren">McLaren</option>
<option value="Mercedes-Benz">Mercedes-Benz</option>
<option value="MG">MG</option>
<option value="Microcar">Microcar</option>
<option value="Mini">Mini</option>
<option value="Mitsubishi">Mitsubishi</option>
<option value="Morgan">Morgan</option>
<option value="Nissan">Nissan</option>
<option value="NSU">NSU</option>
<option value="Oldsmobile">Oldsmobile</option>
<option value="Opel">Opel</option>
<option value="Pagani">Pagani</option>
<option value="Peugeot">Peugeot</option>
<option value="Piaggio">Piaggio</option>
<option value="Plymouth">Plymouth</option>
<option value="Pontiac">Pontiac</option>
<option value="Porsche">Porsche</option>
<option value="Proton">Proton</option>
<option value="Renault">Renault</option>
<option value="Rover">Rover</option>
<option value="Ruf">Ruf</option>
<option value="Saab">Saab</option>
<option value="Santana">Santana</option>
<option value="Seat">Seat</option>
<option value="Skoda">Skoda</option>
<option value="Smart">Smart</option>
<option value="SpeedART">speedART</option>
<option value="Spyker">Spyker</option>
<option value="Ssangyong">Ssangyong</option>
<option value="Subaru">Subaru</option>
<option value="Suzuki">Suzuki</option>
<option value="Talbot">Talbot</option>
<option value="Tata">Tata</option>
<option value="Techart">Techart</option>
<option value="Tesla">Tesla</option>
<option value="Toyota">Toyota</option>
<option value="Triumph">Triumph</option>
<option value="TVR">TVR</option>
<option value="VW">VW</option>
<option value="Volvo">Volvo</option>
<option value="Wartburg">Wartburg</option>
<option value="Westfield">Westfield</option>
<option value="Wiesmann">Wiesmann</option>
<option value="ANDERE">ANDERE</option>
</select>
<label for="chassis" id="label_chassis">Chassis Nummer:</label>
<label for="label_ja" id="label_behandeling2">in behandeling geweest?</label>
<label for="label_ja" id="label_behandeling1">Is de wagen reeds eerder bij ALLRIDE</label>
<label for="merk" id="label_merk">Merk:</label>
<label for="model" id="label_model">Model:</label>
<input type="text" id="model" name="model" value="" tabindex="8" spellcheck="false">
<div id="wb_tekst_adresinvoer">
<span style="color:#000000;font-family:Arial;font-size:13px;">Voer hier het adres in waar het voertuig opgehaald en weer afgeleverd moet worden AUB.</span></div>
<label for="bedrijf" id="label_bedrijf">Bedrijf:</label>
<label for="straat" id="label_straat">Straat+ Nummer:</label>
<label for="plaats" id="label_plaats">Plaats:</label>
<input type="text" id="bedrijf" name="bedrijf" value="" tabindex="10" spellcheck="false">
<input type="text" id="plaats" name="plaats" value="" tabindex="12" spellcheck="false">
<input type="text" id="straat" name="straat" value="" tabindex="11" spellcheck="false">
<input type="text" id="kleur" name="kleur" value="" tabindex="9" spellcheck="false">
<label for="kleur" id="label_kleur">Kleur:</label>
<div id="wb_radiob_ja">
<input type="radio" id="radiob_ja" name="behandeling" value="on"><label for="radiob_ja"></label></div>
<div id="wb_radiob_nee">
<input type="radio" id="radiob_nee" name="behandeling" value="on"><label for="radiob_nee"></label></div>
<label for="radiob_ja" id="label_ja">JA</label>
<label for="radiob_nee" id="label_nee">NEE</label>
<label for="" id="label_gevr_werken">Gevraagde werken</label>
<div id="wb_check_onderhoud">
<input type="checkbox" id="check_onderhoud" name="geen_onderhoud" value="ONDERHOUD" title="ONDERHOUD"><label for="check_onderhoud"></label></div>
<label for="check_onderhoud" id="label_onderhoud" title="ONDERHOUD">ONDRHOUD</label>
<div id="wb_check_banden">
<input type="checkbox" id="check_banden" name="geen_banden" value="BANDEN WISSEL" title="BANDEN WISSEL"><label for="check_banden"></label></div>
<label for="check_banden" id="label_banden" title="BANDEN WISSEL">BANDEN WISSEL (zomer<>winter)</label>
<div id="wb_check_remmen">
<input type="checkbox" id="check_remmen" name="geen_remmen" value="REMMEN" title="REMMEN"><label for="check_remmen"></label></div>
<label for="check_remmen" id="label_remmen" title="REMMEN">REMMEN</label>
<div id="wb_check_keuring">
<input type="checkbox" id="check_keuring" name="geen_keuring" value="NAZICHT KEURING" title="NAZICHT KEURING"><label for="check_keuring"></label></div>
<label for="check_keuring" id="label_keuring" title="NAZICHT KEURING">NAZICHT KEURING</label>
<div id="wb_check_andere">
<input type="checkbox" id="check_andere" name="geen_andere" value="ANDERE (zie opmerkingen)" title="ANDERE (zie opmerkingen)"><label for="check_andere"></label></div>
<label for="check_andere" id="label_andere" title="ANDERE (zie opmerkingen)">ANDERE (zie opmerkingen)</label>
<div id="wb_text_andere">
<span style="color:#FF0000;font-family:Arial;font-size:13px;">LET OP: werken moeten uitvoerbaar zijn binnen de opgegeven tijd.</span></div>
<div id="wb_tekst_weekvoorhand">
<span style="color:#000000;font-family:Arial;font-size:16px;"><em>Kies gewenste datum voor uw afspraak.<br></em></span><span style="color:#FF0000;font-family:Arial;font-size:19px;"><strong><em>Gelieve een week of meer vooruit te plannen.</em></strong></span></div>
<div id="wb_tekst_locatieuur">
<span style="color:#000000;font-family:Arial;font-size:13px;">Het voertuig staat op locatie vanaf:</span></div>
<label for="uur_begin" id="label_begin">Begin uur:</label>
<input type="time" id="uur_begin" name="uur_begin" value="" tabindex="15" spellcheck="false">
<label for="" id="label_terug">uur terug:</label>
<input type="time" id="uur_terug" name="uur_terug" value="" tabindex="16" spellcheck="false">
<input type="submit" id="but_verzenden" name="Verzenden" value="Verzenden" tabindex="15">
</form>
</div>
<div id="wb_page1IconFont1">
<a href="./index.html"><div id="page1IconFont1"><i class="material-icons"></i></div></a></div>
<div id="wb_page1Text1">
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