<div id="nomis-request" class="nomis-form">

	<?php if (!empty($data['success'])) : ?>
	<p class="success"><?php _e('You successfully contacted us, we\'ll get back to you as soon as possible!', 'nomis'); ?></p>
	<?php else : ?>

	<?php if (@$data['error'] == true) : ?>
	<p class="error"><?php _e('Error occurred, please review.', 'nomis'); ?></p>
	<?php endif; ?>

	<form action="" method="post">
		<dl>
			<?php foreach ($data['form'] as $name => $info)
			{
				echo $this->formText($name,
					@$info['info'],
					@$info['options']);
			}?>
			<dt>&nbsp;</dt>
			<dd><input type="submit" value="<?php echo __('Send', 'nomis'); ?>" name="add_single_request" class="submit" /></dd>
		</dl>
	</form>

	<?php endif; ?>

</div>