<div class="modal-header">
    <button type="button" class="close" data-dismiss="modal">&times;</button>
    <h2 class="modal-title"><?php echo $heading; ?></h2>
    <!--Click to select if we Exceeded, Met or Did Not meet your Expectations-->
</div>

<div class="modal-body">
    <div class="row">

        <div class="form-group-lg form-group-select-plus pull-left width100per">
            <div class="col-sm-6">

                <div class="group"> 
                    <div class="spanclass">City</div>
                    <input class="inputMaterial" type="text">
                    <span class="highlight"></span>
                    <span class="bar"></span>


                </div>



            </div>

            <div class="col-sm-6">

                <div class="group">    
                    <div class="spanclass">Package</div>
                    <input class="inputMaterial" type="text" >
                    <span class="highlight"></span>
                    <span class="bar"></span>


                </div>



            </div>
        </div>

        <div class="form-group-lg form-group-select-plus pull-left width100per">

            <div class="col-sm-6">

                <div class="group">    
                    <div class="spanclass">Pickup Location</div>
                    <input class="inputMaterial" type="text" >
                    <span class="highlight"></span>
                    <span class="bar"></span>


                </div>



            </div>

            <div class="col-sm-6">

                <div class="group">      
                    <div class="spanclass">Pickup Address</div>
                    
                   
                        <input class="inputMaterial" type="text" >
                 
                    <span class="highlight"></span>
                    <span class="bar"></span>

                </div>
            </div>
        </div>

        <div class="form-group-lg form-group-select-plus pull-left width100per margin-bot20px"style="margin-bottom: 18px;">


            <div class="col-sm-6">

                <div class="group">      
                    <div class="spanclass"> Nationality </div>
                    <span class="bar"></span>
                    <div class="select-style">
                        <select class="inputMaterial" >
                            <option value="January-March">Indian</option>
                            <option value="April-June">American</option>
                            <option value="July-September">British</option>
                            <option value="October-December">Russian</option>  
                        </select>
                    </div>
                    <span class="highlight"></span>
                    <span class="bar"></span>

                </div>



            </div>


            <div class="col-sm-6">
                
               
                <div class="col-md-12 no-padding" id="round_trip">
                    <div class="form-group-lg form-group-icon-left">
                        <div class="col-sm-6 padding0">
                            <div class="group">
                                <div class="spanclass">Date</div>
                                <input type="text" name="pickup_date" id="pickup-date" placeholder="Date" class="inputMaterial datepicker hasDatepicker" value="">                                                                <span class="highlight"></span>
                                <span class="bar"></span>
                            </div>
                        </div>

                        <div class="col-sm-6 paddig-right0">
                            <div class="group">
                                <div class="spanclass">Time</div>
                                <div class="input-group clockpicker" data-placement="bottom" data-align="left" data-donetext="Done">
                                    <input type="text" name="pickup_time" id="pickup-time" placeholder="Time" class="inputMaterial" value="">                                                                        <span class="input-group-addon">
                                        <span class="glyphicon glyphicon-time"></span>
                                    </span>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
           

             
            </div>

        </div>

        <div class="form-group-lg form-group-select-plus pull-left width100per">


            <div class="col-sm-3">

                <div class="form-group-lg form-group-select-plus">


                        <div class="group adult quantity">

                            <input type="number" name="adults" id="adults" class="inputMaterial test" min="0" max="9" step="1" value="1"><div class="quantity-nav"><div class="quantity-button quantity-up"></div><div class="quantity-button quantity-down"></div></div>
                            <span class="highlight"></span>
                            <span class="bar"></span>
                            <label for="adults">Adults</label>                        </div>


                    </div>
            </div>

            <div class="col-sm-3">

                <div class="form-group-lg form-group-select-plus">
                        <div class="group chield quantity">
                            <input type="number" name="childs" id="childs" class="inputMaterial test" min="0" max="9" step="1" value="0"><div class="quantity-nav"><div class="quantity-button quantity-up"></div><div class="quantity-button quantity-down"></div></div>                                                        <span class="highlight"></span>
                            <span class="bar"></span>
                            <label for="childs">Childs</label>                        </div>
                    </div>
            </div>
            
            <div class="col-sm-3">

                <div class="form-group-lg form-group-select-plus">


                        <div class="group laggage quantity">


                            <input type="number" name="luggages" id="luggages" class="inputMaterial" min="0" max="9" step="1" value="0"><div class="quantity-nav"><div class="quantity-button quantity-up"></div><div class="quantity-button quantity-down"></div></div>                            <span class="highlight"></span>
                            <span class="bar"></span>
                            <label for="luggages">Luggages</label>                        </div>

                    </div>



            </div>
            
            <div class="col-sm-3">

               <div class="form-group-lg form-group-select-plus">


                        <div class="group car quantity">

                            <input type="number" name="no_of_vehicles" id="no-of-vehicles" class="inputMaterial test" min="1" max="9" step="1" value="1"><div class="quantity-nav"><div class="quantity-button quantity-up"></div><div class="quantity-button quantity-down"></div></div>
                            <span class="highlight"></span>
                            <span class="bar"></span>
                            <label for="no-of-vehicles">Vehicles</label>                        </div>

                    </div>



            </div>

        </div>
       
        <div class="form-group-lg form-group-select-plus pull-left width100per" style="margin-top: 20px;">

            <div class="col-md-8 no-padding">

                <div class="col-md-8">             
                    <div class="group">  

                        <div class="spanclass"> Enter Captcha  </div>
                        <input class="inputMaterial" type="text" required>
                        <span class="highlight"></span>
                        <span class="bar"></span>


                    </div>

                </div>
                <div class="col-sm-4">
                    <div class="spanclass">Captcha</div>
                    <input type="text" value="1376" id="ran" readonly="readonly" class="captcha form-control valid" aria-invalid="false"></div>

            </div>

            <div class="col-sm-4 text-right">
                <div class="spanclass"></div>
                <div class="group">      
                    <button class="btn btn-danger" type="submit">Submit</button>
                </div>
            </div>



        </div>

    </div>



</div>
</div>
<div class="modal-footer" style=" padding-top:2px !important;">
    <button type="button" class="btn btn-default" data-dismiss="modal">Close</button>
</div>