Contact Test Page

First Name* Last Name* Title Email* Concerning* Application Type* Product(s)

<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Application Information<span class="requiredStar">*</span></span>
            <textarea onkeypress="javascript:TextareaMaxLength(this, 2000);" onkeyup="javascript:TextareaMaxLength(this, 2000);" id="Notes/Instructions" name="Notes/Instructions" 
				style="height:100px; font-family:Verdana;" cols="10" rows="10"/>
			
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Company Name<span class="requiredStar">*</span></span>
            <input type="text" id="Company Text Field" name="Company Text Field" maxlength="100" style="font-family:Verdana;" value="" />
         
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Phone<span class="requiredStar">*</span></span>
            <input type="text" id="Contact:  Phone" name="Contact:  Phone" maxlength="50" style="font-family:Verdana;" value="" />
			
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Address 1</span>
			<input type="text" id="Contact Address 1: Street 1" name="Contact Address 1: Street 1" maxlength="250" style="font-family:Verdana;" value="" />
			
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Address 2</span>
			<input type="text" id="Contact Address 1: Street 2" name="Contact Address 1: Street 2" maxlength="250" style="font-family:Verdana;" value="" />
			
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">City</span>
			<input type="text" id="Contact Address 1: City" name="Contact Address 1: City" maxlength="80" style="font-family:Verdana;" value="" />
			
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">State/Province</span>
			<select id="Ship To State" name="Ship To State" style="font-family:Verdana;">
                <option value="-1" />
                <option value="Alabama">Alabama</option>
                <option value="Alaska">Alaska</option>
                <option value="Alberta">Alberta</option>
                <option value="Arizona">Arizona</option>
                <option value="Arkansas">Arkansas</option>
                <option value="British Columbia">British Columbia</option>
                <option value="California">California</option>
                <option value="Colorado">Colorado</option>
                <option value="Connecticut">Connecticut</option>
                <option value="Delaware">Delaware</option>
                <option value="District of Columbia">District of Columbia</option>
                <option value="Florida">Florida</option>
                <option value="Georgia">Georgia</option>
                <option value="Hawaii">Hawaii</option>
                <option value="Idaho">Idaho</option>
                <option value="Illinois">Illinois</option>
                <option value="Indiana">Indiana</option>
                <option value="Iowa">Iowa</option>
                <option value="Kansas">Kansas</option>
                <option value="Kentucky">Kentucky</option>
                <option value="Louisiana">Louisiana</option>
                <option value="Maine">Maine</option>
                <option value="Manitoba">Manitoba</option>
                <option value="Maryland">Maryland</option>
                <option value="Massachusetts">Massachusetts</option>
                <option value="Michigan">Michigan</option>
                <option value="Minnesota">Minnesota</option>
                <option value="Mississippi">Mississippi</option>
                <option value="Missouri">Missouri</option>
                <option value="Montana">Montana</option>
                <option value="Nebraska">Nebraska</option>
                <option value="Nevada">Nevada</option>
                <option value="New Brunswick">New Brunswick</option>
                <option value="New Hampshire">New Hampshire</option>
                <option value="New Jersey">New Jersey</option>
                <option value="New Mexico">New Mexico</option>
                <option value="New York">New York</option>
                <option value="Newfoundland and Labrador">Newfoundland and Labrador</option>
                <option value="North Carolina">North Carolina</option>
                <option value="North Dakota">North Dakota</option>
                <option value="Northwest Territories">Northwest Territories</option>
                <option value="Nova Scotia">Nova Scotia</option>
                <option value="Nunavut">Nunavut</option>
                <option value="Ohio">Ohio</option>
                <option value="Oklahoma">Oklahoma</option>
                <option value="Ontario">Ontario</option>
                <option value="Oregon">Oregon</option>
                <option value="Pennsylvania">Pennsylvania</option>
                <option value="Prince Edward Island">Prince Edward Island</option>
                <option value="Quebec">Quebec</option>
                <option value="Rhode Island">Rhode Island</option>
                <option value="Saskatchewan">Saskatchewan</option>
                <option value="South Carolina">South Carolina</option>
                <option value="South Dakota">South Dakota</option>
                <option value="Tennessee">Tennessee</option>
                <option value="Texas">Texas</option>
                <option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
                <option value="Utah">Utah</option>
                <option value="Vermont">Vermont</option>
                <option value="Virginia">Virginia</option>
                <option value="Washington">Washington</option>
                <option value="West Virginia">West Virginia</option>
                <option value="Wisconsin">Wisconsin</option>
                <option value="Wyoming">Wyoming</option>
                <option value="Yukon">Yukon</option>
              </select>
         
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Postal Code<span class="requiredStar">*</span></span>
            <input type="text" id="Contact Address 1: Zip/Postal Code" name="Contact Address 1: Zip/Postal Code" maxlength="20" style="font-family:Verdana;" value="" />
			
			<span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Ship To Country<span class="requiredStar">*</span></span>
			<select id="Ship To Country" name="Ship To Country" style="font-family:Verdana;">
                <option value="-1" />
                <option value="Algeria">Algeria</option>
                <option value="Argentina">Argentina</option>
                <option value="Australia">Australia</option>
                <option value="Austria">Austria</option>
                <option value="Bahrain">Bahrain</option>
                <option value="Belarus">Belarus</option>
                <option value="Belgium">Belgium</option>
                <option value="Brazil">Brazil</option>
                <option value="Bulgaria">Bulgaria</option>
                <option value="Cameroon">Cameroon</option>
                <option value="Canada">Canada</option>
                <option value="Chile">Chile</option>
                <option value="China">China</option>
                <option value="Colombia">Colombia</option>
                <option value="Costa Rica">Costa Rica</option>
                <option value="Croatia">Croatia</option>
                <option value="Czech Republic">Czech Republic</option>
                <option value="Denmark">Denmark</option>
                <option value="Dominican Republic">Dominican Republic</option>
                <option value="Ecuador">Ecuador</option>
                <option value="Egypt">Egypt</option>
                <option value="El Salvador">El Salvador</option>
                <option value="Estonia">Estonia</option>
                <option value="Finland">Finland</option>
                <option value="France">France</option>
                <option value="Germany">Germany</option>
                <option value="Gibraltar">Gibraltar</option>
                <option value="Greece">Greece</option>
                <option value="Hong Kong">Hong Kong</option>
                <option value="Hungary">Hungary</option>
                <option value="India">India</option>
                <option value="Indonesia">Indonesia</option>
                <option value="Iran">Iran</option>
                <option value="Ireland">Ireland</option>
                <option value="Israel">Israel</option>
                <option value="Italy">Italy</option>
                <option value="Jamaica">Jamaica</option>
                <option value="Japan">Japan</option>
                <option value="Jordan">Jordan</option>
                <option value="Kenya">Kenya</option>
                <option value="Kuwait">Kuwait</option>
                <option value="Latvia">Latvia</option>
                <option value="Lebanon">Lebanon</option>
                <option value="Liechtenstein">Liechtenstein</option>
                <option value="Lithuania">Lithuania</option>
                <option value="Luxembourg">Luxembourg</option>
                <option value="Malaysia">Malaysia</option>
                <option value="Mexico">Mexico</option>
                <option value="Morocco">Morocco</option>
                <option value="Netherlands">Netherlands</option>
                <option value="New Zealand">New Zealand</option>
                <option value="Nigeria">Nigeria</option>
                <option value="Norway">Norway</option>
                <option value="Oman">Oman</option>
                <option value="Pakistan">Pakistan</option>
                <option value="Peru">Peru</option>
                <option value="Philippines">Philippines</option>
                <option value="Poland">Poland</option>
                <option value="Portugal">Portugal</option>
                <option value="Puerto Rico">Puerto Rico</option>
                <option value="Qatar">Qatar</option>
                <option value="Romania">Romania</option>
                <option value="Russian Federation">Russian Federation</option>
                <option value="Saudi Arabia">Saudi Arabia</option>
                <option value="Singapore">Singapore</option>
                <option value="Republic of Slovenia">Republic of Slovenia</option>
                <option value="South Africa">South Africa</option>
                <option value="South Korea">South Korea</option>
                <option value="Spain">Spain</option>
                <option value="Sri Lanka">Sri Lanka</option>
                <option value="Sudan">Sudan</option>
                <option value="Swaziland">Swaziland</option>
                <option value="Sweden">Sweden</option>
                <option value="Switzerland">Switzerland</option>
                <option value="Taiwan">Taiwan</option>
                <option value="Thailand">Thailand</option>
                <option value="Turkey">Turkey</option>
                <option value="Ukraine">Ukraine</option>
                <option value="United Arab Emirates">United Arab Emirates</option>
                <option value="United Kingdom">United Kingdom</option>
                <option value="United States">United States</option>
                <option value="Uruguay">Uruguay</option>
                <option value="Venezuela">Venezuela</option>
                <option value="Vietnam">Vietnam</option>
              </select>
            
			<span class="maxSize1 minSize1" style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Is this request a result of sales rep visit</span>
			<select id="Result of Sales Rep Visit" name="Result of Sales Rep Visit" style="font-family:Verdana;">
                <option value="-1" />
                <option value="Yes">Yes</option>
                <option value="No">No</option>
              </select>
        
          <span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">How did you hear about us?<span class="requiredStar">*</span> </span>
           <select id="How did you hear about us?" name="How did you hear about us?" style="font-family:Verdana;">
                <option value="-1" />
                <option value="Current Customer">Current Customer</option>
                <option value="Distributor / Agent">Distributor / Agent</option>
                <option value="Advertising">Advertising</option>
                <option value="Search Engine">Search Engine</option>
                <option value="Social Media">Social Media</option>
                <option value="Tradeshow">Tradeshow</option>
                <option value="Word of Mouth">Word of Mouth</option>
                <option value="Other">Other</option>
            </select>
       
			<input id="Send Technical Bullets" name="Send Technical Bullets" type="checkbox" />
            <span style="font-family:Verdana; font-weight:normal; font-size:13px; color:#000000;">Subscribe to Technical Emails</span>
			  
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