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				<div class="alert alert-info" role="alert">
		
					<p>Fill out your contact details and receive price quotes in your Inbox.</p>
					
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		<div class="card-block">

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				<div>
					<form action="xa/products/buy" method="post"  class="large odf_ajax">
	<input type="hidden" name="combo_id" value="4801">
<input type="hidden" name="product_id" value="1526">
<input type="hidden" name="product_title_text" value="Dulbecco’s Modified Eagle’s Medium (DMEM) (Welgene)">
	<table class="key_value">
		<tbody>
									<tr class="">
							<th>
								<label for="5xQ63Xg0K17436375055251">Product</label>
																							</th>
							<td >
								<span >Dulbecco’s Modified Eagle’s Medium (DMEM) (Welgene)</span>
							</td>
						</tr>
												<tr class="">
							<th>
								<label for="dQGG2YpUC17436375055253">Your name</label>
																	<span class="required_input">*</span>
																							</th>
							<td >
								<input type="text" name="name" value="" placeholder="Your name">
							</td>
						</tr>
												<tr class="">
							<th>
								<label for="E1gR33i7617436375055255">Your E-mail</label>
																	<span class="required_input">*</span>
																							</th>
							<td >
								<input type="text" name="email" value="" placeholder="Your E-mail">
							</td>
						</tr>
												<tr class="">
							<th>
								<label for="oZtbF5Jk17436375055255">Your phone number</label>
																							</th>
							<td >
								<input type="text" name="phone" value="" placeholder="Your phone number">
							</td>
						</tr>
									<tr>
				<th></th>
				<td><button type="submit" class="btn btn-success btn-large">Submit</button></td>
			</tr>
		</tbody>
	</table>
</form>
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