	<form action="" method="post">
		<input type="hidden" name="av-reserv-nonce" value="9ce0b64d6c">
		<div class="clearfix">
			<div class="inputs">
				<div class="area">
					<div class="container-fluid">
						<div class="row">
							<div class="col-md-6">
								<div class="col-md-6">
									<span class="input">
									<label for="checkbox-9">9</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-9" value="9">
								</span>
								<span class="input">
									<label for="checkbox-8"> 8</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-8" value="8">
								</span>
								<span class="input">
									<label for="checkbox-7"> 7</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-7" value="7">
								</span>
								<span class="input">
									<label for="checkbox-6"> 6</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-6" value="6">
								</span>
								<span class="input">
									<label for="checkbox-5"> 5</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-5" value="5">
								</span>
							</div>
							<div class="col-md-6 ">
								<span class="input bar">
									<label for="checkbox-15" id="rotateText"></label>
									<input type="checkbox" name="checkbox[]" id="checkbox-15">
								</span>
								<span class="input active-2">
									<label for="checkbox-1"> 1</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-1" value="1">
								</span>
								<span class="input active-2">
									<label for="checkbox-2"> 2</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-2" value="2">
								</span>
								<span class="input">
									<label for="checkbox-3"> 3</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-3" value="3">
								</span>
							</div>
							<div class="col-md-12">
								<span class="input">
									<label for="checkbox-11">4</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-11" value="4">
								</span>
							</div>
							<div class="col-md-6">
								<span class="input">
									<label for="checkbox-12">VIP</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-12" value="10">
								</span>
							</div>
							<div class="col-md-6">
								<span class="input">
									<label for="checkbox-13">VIP</label>
									<input type="checkbox" name="checkbox[]" id="checkbox-13" value="11">
								</span>
							</div>
						</div>
						<div class="col-md-6 text-center">
							<h3 class="r-padding">Інформація по резервуванню</h3>
							<fieldset>
								<div class="form-group clearfix">
									<label class="col-lg-5 control-label" for="customer_name">Ваше ім'я</label>
									<div class="col-lg-7">
										<input class="form-control text-center" type="text" name="customer_name" required="" placeholder="Ваше ім'я">
									</div>
								</div>
								<div class="form-group clearfix">
									<label class="col-lg-5" for="customer_phone">Ваш телефон</label>
									<div class="col-lg-7">
										<input class="form-control text-center" type="tel" name="customer_phone" required="" placeholder="380XXXXXXXXX" pattern="[0-9]{12}">
									</div>
								</div>
								<div class="form-group clearfix">
									<label class="col-lg-5" for="reserv_date">Цільова дата</label>
									<div class="col-lg-7">
										<input class="form-control text-center" style="line-height: inherit;" type="date" name="reserv_date" value="2016-09-13" required="">
									</div>
								</div>
								<div class="text-center col-lg-12">
									<input class="btn btn-warning" type="submit" value="Зарезервировать">
								</div>
							</fieldset>
						</div>
					</div>
				</div>
			</div>
		</div>
	</div>
	</form>
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