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<table width="1246" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <TD WIDTH=1000 valign="TOP"><P ALIGN=LEFT class="style17"><FONT SIZE=2>For customer
      
      service information and/or technical support please fill in the
      
      following form: </FONT> </P></TD>
    <td width="246">&nbsp;</td>
  </tr>
  <tr>
    <TD WIDTH=1000 valign="TOP"><P>
        <div id ="errormessage" style = "display:none;color = Red"  ><font color="RED" size="2" face="Verda na"> Required information is missing, incomplete or not correctly entered. Please correct your entries and try again. </font></div>
      <font size="2" face="Verda na"> Required customer service
        
        information:</font>
        </P>
        <P><FONT FACE="Verdana"><FONT SIZE=2> <Font Color = "Red"> * </Font> <B>First name:</B><BR>
                <INPUT TYPE=TEXT NAME="FIRST NAME" Id = "FIRSTNAME" SIZE=50 maxlength = 100>
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          &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
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          appropriate boxes:
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          <br>
          <input type=CHECKBOX name="APPLICATIONS8" value="Food">
Food Industry</span>
          <span class="style20">
          <br>
          <input type=CHECKBOX name="APPLICATIONS9" value="Immunochem">
Immunochemistry</span>
          <span class="style20">
          <br>
          <input type=CHECKBOX name="APPLICATIONS" value="BioanalyticalChem">
Bioanalytical Chemistry</span>
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          <br>
          <input type=CHECKBOX name="APPLICATIONS2" value="EnvironDiagnostics">
Environmental Diagnostics</span>
          <span class="style20">
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          <input type=CHECKBOX name="APPLICATIONS3" value="Forensics">
Forensics</span>
          <span class="style20">
          <br>
          <input type=CHECKBOX name="APPLICATIONS4" value="BiomedDiagnostics">
Biomedical Diagnostics</span>
        <p>&nbsp;</p>
      <p>Discipline:</FONT></B> </P>
      </p>
              <span class="style20">
              <input type=CHECKBOX name="DISCIPLINE6" value="Biosensors">
Biosensor Development</span>
              <div align="left">
                <TABLE BORDER=0 align="left" CELLPADDING=0 CELLSPACING=2>
                  <TR>
                    <TD><P align="left" class="style20">&nbsp;</P></TD>
                  </TR>
                  <TR>
                    <TD><P align="left" class="style20">
                        <INPUT TYPE=CHECKBOX NAME="DISCIPLINE" VALUE="Electrochemistry">
                      Micro Electrochemistry</P></TD>
                  </TR>
                  <TR>
                    <TD><span class="style20">
                      <input type=CHECKBOX name="DISCIPLINE2" value="ChemSensors">
                      Chemical Sensor Development</span></TD>
                  </TR>
                  <TR>
                    <TD><span class="style20">
                      <input type=CHECKBOX name="DISCIPLINE3" value="HPLC/LCDetectors">
                      HPLC/LC Detection</span></TD>
                  </TR>
                  <TR>
                    <TD><span class="style20">
                      <input type=CHECKBOX name="DISCIPLINE4" value="Polymers">
                      Polymer Materials Characterization</span></TD>
                  </TR>
                  <TR>
                    <TD><span class="style20">
                      <input type=CHECKBOX name="DISCIPLINE5" value="Conductimetry">
                      Conductimetry</span></TD>
                  </TR>
                </TABLE>
              </div>
      <P ALIGN=left><BR>
                  <BR>
              </P>
      <P ALIGN=left>&nbsp;</P>
      <P ALIGN=left>&nbsp;</P>
      <CENTER>
                <TABLE WIDTH=650 BORDER=0 CELLPADDING=0 CELLSPACING=2 align="left">
                  <TR>
                    <TD WIDTH=650><P align="left"><B><span class="style14">Please send me Product Literature on:</span></B></P>
                        <P align="left">
                          <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="EPSIS">
                          <span class="style20">EPSIS - Electroactive Polymer Sensor Interrogation System<BR>
                          <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="EPMES">
                            EPMEs - Electroactive Polymer Transducers <BR>
                            <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="IMES">
                            IMEs - Interdigitated Microsensor Electrodes<BR>
                            <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="IAME/IAIME">
                            IAMEs and IAIMEs - Independently Addressable Microband Electrodes<BR>
                            <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="ECCS">
                            ECCs - Electrochemical Cell-on-a-Chip<BR>
                            <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="MDEAS">
                            MDEAs - Microdisc Electrode Arrays<BR>
                            <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="Accessories">
                            Accessories Catalog - The Laboratory Products Group<BR>
                            <INPUT TYPE=CHECKBOX NAME="LITERATURE" VALUE="BioSenSys">
                            BioSenSys - Handheld Diagnostics Workstation</span><FONT SIZE=2><BR>
                              <BR>
                              </FONT><span class="style22">I have other questions/comments:</span><FONT SIZE=2> <BR>
                                <TEXTAREA NAME="COMMENTS" ></TEXTAREA>
                                <br>
                                <br>
                                </FONT>
                          <input name="submit" type=submit onClick  = "javascript:return validatepage()" value="Submit Form">
                          <input name="RESET" type=RESET value="Clear Form">
                          <font size=2>and start again</font></P></TD>
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    <td><table width=225 border=0 cellpadding=5 cellspacing=0 style="page-break-before: always">
      <tr valign=TOP>
        <td width=215 height="29" bgcolor="#c0c0c0"><p align=LEFT class="style19"><a href="news.html"><span style="background: transparent"><img src="newsletter2.gif" alt="x" width="232" height="53"></span></a></p></td>
      </tr>
      <tr valign=TOP>
        <td width=215 height="298" bgcolor="#EBEBEB"><p align=justify class="style18">ABTECH wishes to maintain a record of
          
          the individuals requesting customer service information. This
          
          record is for administrative purposes only. In the event of
          
          changes or additions to our customer service package, ABTECH
          
          will use this record to notify all requestors of changes or
          
          additions. </p>
            <p align=justify class="style18"><strong>NOTE:</strong> It is
              
              essential that you provide a complete and accurate mailing
              
              address. The web-site version of our product catalogues do not
              
              contain all the necessary technical support information. The
              
              information package you receive contains details of product
              
              specifications and application notes essential to the successful
              
              use of our products. This information package and product
              
              catalog will be mailed to the address you provide on this page.</p>
          <p align=justify class="style18"><b>If you are having problems with
            
            this form:</b><br>
            Be sure that your browser can handle forms. If
            
            your browser cannot use this page, you may request customer
            
            service information by sending an e-mail to <a href="mailto:[email protected]">[email protected]</a> or traditional mail to:</p>
          <p align=justify class="style18">Customer Service Department:<br>
            ABTECH
            
            Scientific, Inc.<br>
            800 East Leigh Street, Suite 52, Richmond,
            
            Virginia 23219. USA<br>
            Tel: +001 804 827 7029<br>
            Fax: +001 804
            
            783 7830</p>
          <p align=justify class="style18">Thank you.</p></td>
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