<a href="#" class="jqmClose"></a>
<h2>Заказать оборудование <span>Honeywell</span></h2>

<form name="call_back" action="/send_order.php" method="post" onsubmit="return TrySend(this)">
    <input type="hidden" name="order" value="true"/>
    <input type="hidden" name="material_id" value="23"/>
    <table class="order_form_t">
        <tr>
            <td width="100%"><input type="text" name="name" class="inplong" required placeholder="ФИО (обязательно)"/></td>
        </tr>
        <tr>
            <td><input type="text" name="phone" class="inplong mask-phone"  placeholder="Телефон"/></td>
        </tr>
        <tr>
            <td><input type="text" name="email" class="inplong"  placeholder="E-mail (обязательно)"/></td>
        </tr>
        <tr>
            <td width="100%"><textarea name="comment" class="talong" placeholder="Дополнительная информация"></textarea></td>
        </tr>
        <tr>

            <td style="padding:10px 0px 10px 5px;">
                <img src="/captcha.php" border="0" width="120" height="20"/>
                <div class="captcha_check" id="captcha_check_callback"></div>
            </td>

        </tr>
        <tr>
            <td>
                <input type="text" value="" name="captcha" required class="captcha_input" check_id="captcha_check_callback" placeholder="Код с картинки (обязательно)"/>
            </td>
        </tr>
        <tr>

            <td><input type="submit" class="btn-blue btn-order" value="ОТправить заказ"/></td>
        </tr>
    </table>
</form>