{% extends "page.html" %}

{% block subtitle %}{{ _('Contact us to create a new account') }}{% endblock %}

{% block primary_content %}
  <section class="module">
    <div class="module-content">
      <h1>{{ _('Contact us to create a new account') }}</h1>
      <p>{{ _('Please fill in the form below and we will get back to you shortly.') }}</p>

      <form method="post" action="" class="form-horizontal account-request-form">
        {{ h.csrf_input() }}

        <div class="control-group">
          <label class="control-label" for="field-email">{{ _('Email address') }}</label>
          <div class="controls">
            <input id="field-email" class="form-control" type="email" name="email" value="{{ email or '' }}" placeholder="name@example.com" autocomplete="email" required>
            <p class="help-block">{{ _('We will use this to contact you back.') }}</p>
          </div>
        </div>

        <div class="control-group">
          <label class="control-label" for="field-name">{{ _('Your name') }}</label>
          <div class="controls">
            <input id="field-name" class="form-control" type="text" name="name" value="{{ name or '' }}" placeholder="{{ _('Jane Doe') }}" autocomplete="name" required>
          </div>
        </div>

        <div class="control-group">
          <label class="control-label" for="field-message">{{ _('Message') }}</label>
          <div class="controls">
            <textarea id="field-message" class="form-control" name="message" rows="6" placeholder="{{ _('Tell us briefly why you need an account...') }}" required>{{ text or '' }}</textarea>
            <p class="help-block">{{ _('Please include your affiliation and intended use if applicable.') }}</p>
          </div>
        </div>

        <div class="form-actions">
          <button type="submit" class="btn btn-primary">{{ _('Send request') }}</button>
          <a class="btn" href="{{ h.url_for('home.index') }}">{{ _('Cancel') }}</a>
        </div>
      </form>
    </div>
  </section>
{% endblock %}

{% block secondary_content %}
  <section class="account-request-aside">
    <div class="module-content">
      <div class="account-request-icon" aria-hidden="true">
        <i class="fa fa-user-circle"></i>
      </div>
    </div>
  </section>
{% endblock %}