{% include 'header.twig' %}
<div id="page-wrapper">
      <div class="inner-page-wrapper"><div class="container-fluid neworder">
  <div class="row">
<div class="container">
    <div class="row">
      <div class="col-md-8 col-md-offset-2">
        <div class="well ">
        {{ contentText }}
    </div>
  </div>
</div>
</div>
 
    <div class="container">
    <div class="row">
    <div class="col-md-8 col-md-offset-2">
		<div class="well ">
    <form name="contact-form" action="get_response.php" method="post" id="contact-form">
    <div class="form-group">
    <label for="Domain">Domain</label>
    <input type="text" class="form-control" name="domain" placeholder="Domain" required>
    </div>
		 <div class="alert alert-info " id="orderNote">
            <p class="help-block" style="margin-bottom: 5px">Please visit your registrars dashboard to change nameservers to:</p><ul style="color: #737373; padding-left: 20px"><li>ns1.hostwithbest.in</li><li>ns2.hostwithbest.in</li></ul>        </div>
    
		
		<div class="form-group">
        
<label class="Domain" for="currency">Currency</label>
			
		<select class="form-control" name="currency" required>
<option value="USD">United States Dollars (USD)</option>
<option value="INR">Indian Rupee (INR)</option>
</select>
    </div>
	
    <div class="form-group">
    <label for="exampleInputEmail1">Username</label>
    <input type="text" class="form-control" name="your_email" placeholder="Username" required>
    </div>
		
		  <div class="form-group">
        
<label class="control-label" for="orderpanelform-password">Password</label><input type="password" class="form-control" name="password" placeholder="Password" required>
    </div>
		
		
    
    <div class="form-group">
              <label for="charge" class="control-label">{{ lang["neworder.charge"] }}</label>
              <input type="text" class="form-control" value="$25.00" readonly>
            </div>
    <button type="submit" class="dash-btn" name="submit" value="Submit" id="submit_form">Submit Order</button>
    
    </form>
    <div class="response_msg"></div>
    
    <script src="http://ajax.googleapis.com/ajax/libs/jquery/1.11.2/jquery.min.js"></script>
   
    
{% include 'footer.twig' %}
