unserver-unify/src/app/help/request.html

<div class="contact_holder" ng-controller="RequestCtrl as ctrl">
  <div class="mb-margin-bottom-30 col-md-12">
    <div class="tag-box">
      <div class="margin-bottom-20">
        <div class="headline" style="margin-top: 0;">
          <h3 translate="">
            Request Information
          </h3>
        </div>
      </div>
      <form class="form-horizontal" name="form" ng-class='{"shake":shaking}'>
        <div class="form-group"  ng-class='{"has-error":form.category.$invalid && submitted}'>
          <label class="control-label col-md-3" for="category">
            <span>
              {{'Category' | translate}}
            </span>
            <span class="manditory">
              *
            </span>
          </label>
          <div class="col-md-7">
            <select class="form-control" name="category" ng-model="ctrl.info.category" ng-options="item.key as item.key for item in ctrl.Categorys" required="">
              <option translate="" value="">
                Select
              </option>
            </select>
          </div>
        </div>
        <div class="form-group" ng-class='{"has-error":form.fullname.$invalid && submitted}'>
          <label class="control-label col-md-3" for="name">
            <span translate="">
              Name
            </span>            
            <span class="manditory">
              *          
            </span>
          </label>
          <div class="col-md-7">
            <input class="form-control" name="fullname" ng-model="ctrl.info.fullname" type="text" required="" />
          </div>
        </div>
        <div class="form-group" ng-class='{"has-error":form.email.$invalid && submitted}'>
          <label class="control-label col-md-3" for="email">
            <span>
              {{'Email' | translate}}
            </span>
            <span class="manditory">
              *
            </span>
          </label>
          <div class="col-md-7 col-md-offset-0">
            <input class="form-control" name="email" ng-model="ctrl.info.email" required="" type="email"/>
          </div>
        </div>
        <div class="form-group">
          <label class="control-label col-md-3" for="birthday">
            <span translate="">
              Birthday
            </span>
          </label>
          <div class="col-md-7 col-md-offset-0">
            <input class="form-control" name="birthday"  ng-model="ctrl.info.birthday" type="date"/>
          </div>
        </div>
        <div class="form-group">
          <label class="control-label col-md-3" for="phone">
            <span translate="">
              Mobile
            </span>
          </label>
          <div class="col-md-7 col-md-offset-0">
            <input class="form-control" name="phone"  ng-model="ctrl.info.phone" type="tel"/>
          </div>
        </div>
        <div class="form-group">
          <label class="control-label col-md-3" for="education">
            <span translate="">
              Education
            </span>
          </label>
          <div class="col-md-7">
            <select class="form-control" name="education" ng-model="ctrl.info.education">
              <option translate="" value="Phd">
                P.H.D / Doctor
              </option>
              <option translate="" value="Master">
                Master
              </option>
              <option translate="" value="Bachelor">
                Bachelor / University
              </option>
              <option translate="" value="Diploma">
                Diploma
              </option>
              <option translate="" value="ITE">
                ITE
              </option>
              <option translate="" value="Ot">
                Other
              </option>
            </select>
          </div>
        </div>
        <div class="form-group">
          <label class="control-label col-md-3">
            <span translate="">
              School
            </span>
          </label>
          <div class="col-md-7 col-md-offset-0">
            <input class="form-control" name="school"  ng-model="ctrl.info.school" type="text"/>
          </div>
        </div>
        <div class="form-group" ng-class='{"has-error":form.title.$invalid && submitted}'>
          <label class="control-label col-md-3" for="title">
            <span translate="">
              Program
            </span>
            <span class="manditory">
              *
            </span>
          </label>
          <div class="col-md-7">
            <input class="form-control" name="title"  ng-model="ctrl.info.title" required="" type="text"/>
          </div>
        </div>
        <div class="form-group" ng-class='{"has-error":form.content.$invalid && submitted}'>
          <label class="control-label col-md-3" for="content">
            <span>
              {{'Detail' | translate}}
            </span>
            <span class="manditory">
              *
            </span>
          </label>
          <div class="col-md-7">
            <textarea class="form-control" name="content"  ng-model="ctrl.info.content" required="" rows="5">
            </textarea>
          </div>
        </div>
        <div class="form-group" ng-class='{"has-error":form.userCaptcha.$invalid && submitted}'>
          <label class="control-label col-md-3" for="title">
            <span>
              {{'Captcha' | translate}}
            </span>
            <span class="manditory">
              *
            </span>
          </label>
          <div class="col-md-3">
            <div class="input-group">
              <input class="form-control captcha_bg" ng-model="ctrl.captchaCode" readonly="" type="text" />
              <a class="input-group-addon bg-color-blue" ng-click="ctrl.generateCaptcha();">
                <i class="fa fa-refresh color-white"></i>
              </a>
            </div>
          </div>
          <div class="col-md-4">
            <input class="form-control" required="" name="userCaptcha" ng-model="ctrl.userCaptcha" placeholder="{{'Enter the captcha text here' | translate}}" type="text" />
          </div>
        </div>
        <div class="form-group">
          <label class="control-label col-md-3">
          </label>
          <div class="col-md-7">
            <button class="btn btn-u" ng-click="ctrl.createRequest()" type="submit" translate="">
              Send Message
            </button>
          </div>
        </div>
      </form>
    </div>
  </div>
  <div class="clearfix"></div>
</div>