<?php
// Append Host Name and requested resource location
$pageurl = $_SERVER['HTTP_HOST'].$_SERVER['REQUEST_URI'];
?>
<!--================ Start Header Menu Area =================--> 
<form class="form kol_cmn_frm" action="./webform_pre.php" name="form14" id="form14" method="POST" style="margin-bottom:20px; background-color:#1c1c1c; padding: 1px 20px;">
<input type="hidden" id="txturl" name="txturl" value="<?php echo $pageurl;?>" />
  <div class="messages" style="color: #ec171f;font-weight: bold;font-size:18px;margin-bottom:10px;"></div> 
   <div class="row"> 

	<div class="col-lg-3">
        <div class="form-group">
    
            <!--<label class="control-label " for="txtname">Name <span class="asteriskField" style="color:#F00">*</span></label>-->
    
            <input class="form-control" id="txtname" name="txtname" type="text" placeholder="Enter your name" required/>
    
        </div>
    </div>
	<div class="col-lg-2">
         <div class="form-group"> 
    
            <!--<label class="control-label" for="subject">Phone Number <span class="asteriskField" style="color:#F00">*</span></label>-->
    
            <input class="form-control" id="contact" name="contact" type="text" placeholder="Enter phone number" required/>
    
        </div>
    </div>
	<div class="col-lg-2">
        <div class="form-group"> 
    
            <!--<label class="control-label requiredField" for="email">Email  <span class="asteriskField" style="color:#F00">*</span></label>-->
    
            <input class="form-control" id="email" name="email" type="email" placeholder="Enter your email"required/>
    
        </div>
    </div>
	<div class="col-lg-2">
        <div class="form-group"> 
    
            <!--<label class="control-label " for="subject">State & City <span class="asteriskField" style="color:#F00">*</span> </label>-->
    
            <input class="form-control" id="location" name="location" type="text" placeholder="Enter your location"required/>
    
        </div>
    </div>
    
    <div class="col-lg-3">
       <div class="form-group" style="text-align:center;">         
        
            <center><button type="submit" class="btn btn-danger" name="submit_all_course" id="submit_all_course" style="width:100%;">Talk to a Program Advisor
</button></center>
        
         </div>   
        
          
    </div>
    </div>
    
    
	
        
 </div>
 

</form>