%form.form-type-material{:action => "{{route('interested')}}", :method => "POST"}
  = csrf_field()
  %input{:name => "landing", :type => "hidden", :value => "{{$landing or 'No landing'}}"}

  - if(isset($_GET["_rdr"]))
    %input{:name => "origin", :type => "hidden", :value => "{{$_GET['_rdr']}}"}
  - else
    %input{:name => "origin", :type => "hidden", :value => "ninguno"}

  .row
    .col-md-12
      .form-group
        %label.black-text-2 <i class="fa fa-user"></i> Tu nombre completo*
        %input.form-control{:name => "name", :type => "text", :value => "{{old('name')}}", :placeholder => "Ej. Martín Alejandro Taméz", :required => "", :tabindex => "1"}/
    .col-md-6
      .form-group
        %label.black-text-2 <i class="fa fa-phone"></i> Teléfono de contacto*
        %input#phone.form-control{:name => "phone", :required => "", :value => "{{old('phone')}}", :placeholder => "Agrega clave LADA", :type => "text", :tabindex => "2"}/
    .col-md-6
      .form-group
        %label.black-text-2 <i class="fa fa-envelope"></i> Correo electrónico*
        %input.form-control{:name => "email", :type => "email", :value => "{{old('email')}}", :placeholder => "Ej. correo@dominio.com", :required => "", :tabindex => "3"}/
    .col-md-12
      .form-group
        %label.black-text-2 <i class="fa fa-building"></i> Empresa o negocio*
        %input.form-control{:name => "extra1", :type => "text", :required => "",:value => "{{old('extra1')}}",:placeholder => "Empresa interesada en los servicios", :tabindex => "4"}/
    .col-md-12
      .form-group
        %label.black-text-2 <i class="fa fa-cubes"></i> Servicio de interés*
        %select.form-control{:name => "extra2", :required => "", :tabindex => "5"}
          %option{:disabled => "disabled", :selected => "selected", :value => "{{old('extra2')}}"} Selecciona una opción por favor
          %option{:value => "Páginas web"} Páginas web
          %option{:value => "Google Adwords"} Google Adwords
          %option{:value => "Publicidad Facebook"} Publicidad en Facebook
          %option{:value => "Diseño gráfico"} Diseño gráfico
          %option{:value => "Otro"} Otros
  .row
    .offset-md-1.col-md-10.text-center.btn-form-modal
      %br/
      %button.btn.btn-bold.btn-block.btn-danger{:type => "submit"} Solicitar información >>