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<input type="hidden" name="csrfmiddlewaretoken" value="ErUvsvzWFJKw25y0VUesq4yCJ0eoMi3omJapAFRJrDXoa6NEXVl4eADFXvkvVtuA"> <div class="form-group"> <div class="row"> <div class="col-md-6 col-sm-6"> <label for="surnameCustomer">Фамилия *</label> <input type="text" class="form-control history" name="last_name" id="surnameCustomer" data-id="1" required="" placeholder="Иванов" value=""> </div> <div class="col-md-6 col-sm-6"> <label for="forenameCustomer">Имя *</label> <input type="text" class="form-control history" name="first_name" id="forenameCustomer" required="" placeholder="Иван" value="" data-id="2"> </div> </div> </div> <div class="form-group"> <div class="row"> <div class="col-md-6 col-sm-6"> <label for="patronymicCustomer">Отчество </label> <input type="text" class="form-control history" name="middle_name" id="patronymicCustomer" placeholder="Иванович" value="" data-id="3"> </div> <div class="col-md-6 col-sm-6"> <label for="birthdayCustomer">Дата рождения *</label> <input type="tel" class="form-control indent history" name="birthday" data-id="5" id="birthdayCustomer" required="" placeholder="01.01.1985" data-mask="00.00.0000" value="" autocomplete="off" maxlength="10" start="1581262599357"> </div> </div> </div> <div class="form-group"> <div class="row"> </div> </div> <div class="form-group margin-top-25"> <label> <input type="checkbox" id="checkbox" class="checkbox" name="agreement" value="yes" required="" checked=""> <span class="checkbox-custom"></span> <span class="label">Я согласен с <a target="blank" href="..\..\docs\">публичной офертой</a> и на <a target="blank" href="..\..\docs\pd_agree.pdf">обработку персональных данных</a></span></label> </div> <input type="hidden" name="history_pasted_1" class="history-pasted-1" value="0"> <input type="hidden" name="history_pasted_2" class="history-pasted-2" value="0"> <input type="hidden" name="history_pasted_3" class="history-pasted-3" value="0"> <input type="hidden" name="history_pasted_5" class="history-pasted-5" value="0"> <input type="hidden" name="history_pasted_7" class="history-pasted-7" value="0"> <input type="hidden" name="history_pasted_8" class="history-pasted-8" value="0"> <input type="hidden" name="history_spend_1" class="history-spend-1" value="0"> <input type="hidden" name="history_spend_2" class="history-spend-2" value="0"> <input type="hidden" name="history_spend_3" class="history-spend-3" value="0"> <input type="hidden" name="history_spend_5" class="history-spend-5" value="0"> <input type="hidden" name="history_spend_7" class="history-spend-7" value="0"> <input type="hidden" name="history_spend_8" class="history-spend-8" value="0"> <input type="hidden" name="private_mode" id="pm" value="2"> <div class="col-md-12 col-sm-12 center-block margin-top-15"> <button class="btn link" type="submit" onclick="location.href='/forms/registration/oplata.html'"> Проверить </button> |
