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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
"http://www.w3.org/TR/REC-html40/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<title>Register to Win!</title>
<style type="text/css" media="all">
td.lbl {font-weight: bold; text-align: right;}
td.sub_lbl {font-weight: bold; text-align: right;}
div.formEnd {text-align: center; padding-top: 1em; margin-top: 1em;}
</style>
<style type="text/css" media="print">
td {padding: 0.5em 0.125em;}
tr.required td.lbl {text-decoration: underline;}
.writein {border-width: 0; border-bottom: 1px solid black;}
select.writein {display: none;}
span#stateBlank {display: block; width: 10em; height: 1em; border-bottom: 1px solid black;}
div#submitArea {display: none;}
div#mailArea p:first-line {font-weight: bold;}
</style>
<style type="text/css" media="screen">
h1 {font-family: sans-serif; border-bottom: 0.125em solid #F33;
margin-bottom: 0;}
td {padding: 0.25em 1px;}
tr.required td.lbl {background: #FCC; border-left: 0.5em solid red;}
td.lbl {
background-color: #66CCFF;
border-left-width: 0.5em;
border-left-style: solid;
border-left-color: #0000FF;
}
div#mailArea {display: none;}
input.writein:focus {background: yellow;}
</style>
<script type="text/javascript" src="calendarDateInput.js"></script>
</head>
<body>
<form method="post" action="http://www.biehlcollects.com/employmail.php" name="SampleForm">
<input type="hidden" name="env_report" value="REMOTE_HOST,REMOTE_ADDR,HTTP_USER_AGENT,AUTH_TYPE,REMOTE_USER">
<!-- STEP 2: Put your email address in the 'recipients' value.
Note that you also have to allow this email address in the
$TARGET_EMAIL setting within formmail.php!
-->
<input type="hidden" name="recipients" value="[email protected]" />
<!-- STEP 3: Specify required fields in the 'required' value -->
<!--<input type="hidden" name="required" value="email:Your email address,realname:Your name" />-->
<!-- STEP 4: Put your subject line in the 'subject' value. -->
<input type="hidden" name="subject" value="employment opps form" />
<h4 align="center">Please complete this form and submit to Biehl & Biehl, Inc.<br>
We will contact you to schedule an appointment.<br>
<font color="#FF0000">Areas in red are required information.</font><br>
Thank you for your interest.</h4>
<table cellspacing="0">
<tr class="required">
<td class="lbl">First name:</td>
<td class="inp"><input type="text" class="writein" name="emFName" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">Last name:</td>
<td class="inp"><input type="text" class="writein" name="emLName" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">Address</td>
<td class="inp"><input type="text" class="writein" name="emAddress" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">City</td>
<td class="inp"><input type="text" class="writein" name="emCity" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">State of residence:</td>
<td><select name="emState">
<option>Alabama</option>
<option>Alaska</option>
<option>Arizona</option>
<option>Arkansas</option>
<option>California</option>
<option>Colorado</option>
<option>Connecticut</option>
<option>Delaware</option>
<option>District of Columbia</option>
<option>Florida</option>
<option>Georgia</option>
<option>Hawaii</option>
<option>Idaho</option>
<option>Illinois</option>
<option>Indiana</option>
<option>Iowa</option>
<option>Kansas</option>
<option>Kentucky</option>
<option>Louisiana</option>
<option>Maine</option>
<option>Maryland</option>
<option>Massachusetts</option>
<option>Michigan</option>
<option>Minnesota</option>
<option>Mississippi</option>
<option>Missouri</option>
<option>Montana</option>
<option>Nebraska</option>
<option>Nevada</option>
<option>New Hampshire</option>
<option>New Jersey</option>
<option>New Mexico</option>
<option>New York</option>
<option>North Carolina</option>
<option>North Dakota</option>
<option>Ohio</option>
<option>Oklahoma</option>
<option>Oregon</option>
<option>Pennsylvania</option>
<option>Rhode Island</option>
<option>South Carolina</option>
<option>South Dakota</option>
<option>Tennessee</option>
<option>Texas</option>
<option>Utah</option>
<option>Vermont</option>
<option>Virginia</option>
<option>Washington</option>
<option>West Virginia</option>
<option>Wisconsin</option>
<option>Wyoming</option>
</select></td>
</tr>
<tr class="required">
<td class="lbl">Zip code:</td>
<td class="inp"><input type="text" class="writein" name="emZip" size="20" maxlength="20"></td>
</tr>
<tr class="required">
<td class="lbl">E-mail:</td>
<td class="inp"><input type="text" class="writein" name="emEmail" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">Phone:</td>
<td class="inp"><input type="text" class="writein" name="emPhone" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">Position Desired:</td>
<td class="inp"><input type="text" class="writein" name="emPosDesired" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">Employment Status:</td><td>
<input type="radio" name="emFT" value="other">Full Time
<input type="radio" name="emPT" value="HS">Part Time
<input type="radio" name="emPerm" value="BABS">Permanent
<input type="radio" name="emTemp" value="Mast">Temporary
<input type="radio" name="emSummer" value="PhD">Summer
</td>
<tr class="required">
<td class="lbl">Education:</td>
<td>
<input type="radio" name="emHS" value="HS">High school
<input type="radio" name="emBaBs" value="BABS">BA/BS
<input type="radio" name="emMasters" value="Mast">Masters
<input type="radio" name="emPhD" value="PhD">Ph.D.
<input type="radio" name="emOther" value="other">other</td>
</tr>
<td class="sub_lbl">
<h4>Previous Employer</h4></td>
<td>(most recent first)</td>
<tr>
<td class="lbl">Company Name:</td>
<td class="inp"><input type="text" class="writein" name="emCo1Name" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">Address</td>
<td class="inp"><input type="text" class="writein" name="emCo1Address" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">City</td>
<td class="inp"><input type="text" class="writein" name="emCo1City" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">State:</td>
<td><select name="emCo1State">
<option>Alabama</option>
<option>Alaska</option>
<option>Arizona</option>
<option>Arkansas</option>
<option>California</option>
<option>Colorado</option>
<option>Connecticut</option>
<option>Delaware</option>
<option>District of Columbia</option>
<option>Florida</option>
<option>Georgia</option>
<option>Hawaii</option>
<option>Idaho</option>
<option>Illinois</option>
<option>Indiana</option>
<option>Iowa</option>
<option>Kansas</option>
<option>Kentucky</option>
<option>Louisiana</option>
<option>Maine</option>
<option>Maryland</option>
<option>Massachusetts</option>
<option>Michigan</option>
<option>Minnesota</option>
<option>Mississippi</option>
<option>Missouri</option>
<option>Montana</option>
<option>Nebraska</option>
<option>Nevada</option>
<option>New Hampshire</option>
<option>New Jersey</option>
<option>New Mexico</option>
<option>New York</option>
<option>North Carolina</option>
<option>North Dakota</option>
<option>Ohio</option>
<option>Oklahoma</option>
<option>Oregon</option>
<option>Pennsylvania</option>
<option>Rhode Island</option>
<option>South Carolina</option>
<option>South Dakota</option>
<option>Tennessee</option>
<option>Texas</option>
<option>Utah</option>
<option>Vermont</option>
<option>Virginia</option>
<option>Washington</option>
<option>West Virginia</option>
<option>Wisconsin</option>
<option>Wyoming</option>
</select></td>
</tr>
<tr>
<td class="lbl">Zip code:</td>
<td class="inp"><input type="text" class="writein" name="emCo1Zip" size="20" maxlength="20"></td>
</tr>
<tr>
<td class="lbl">Position held:</td>
<td class="inp"><input type="text" class="writein" name="emCo1PosHeld" size="60" maxlength="60"></td>
</tr>
<tr>
<td class="lbl">Name & Title of<br>
Immediate Supervisor</td>
<td class="inp"><input type="text" class="writein" name="emCo1NTofSup" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">starting date:</td>
<td>
<script>DateInput('start1', true, 'DD-MON-YYYY')</script>
</td>
</tr>
<td class="lbl">date left:</td>
<td><script>DateInput('left1', true, 'DD-MON-YYYY')</script></td>
</tr>
<td class="lbl">salary:</td>
<td class="inp"><input type="text" class="writein" name="emCo1Salary" size="20" maxlength="20"></td>
</tr>
<td class="sub_lbl">
<h4>Previous Employer</h4></td>
<td>(most recent first)
<tr>
<td class="lbl">Company Name:</td>
<td class="inp"><input type="text" class="writein" name="emCo2Name" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">Address</td>
<td class="inp"><input type="text" class="writein" name="emCo2Address" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">City</td>
<td class="inp"><input type="text" class="writein" name="emCo2City" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">State:</td>
<td><select name="emCo2State">
<option>Alabama</option>
<option>Alaska</option>
<option>Arizona</option>
<option>Arkansas</option>
<option>California</option>
<option>Colorado</option>
<option>Connecticut</option>
<option>Delaware</option>
<option>District of Columbia</option>
<option>Florida</option>
<option>Georgia</option>
<option>Hawaii</option>
<option>Idaho</option>
<option>Illinois</option>
<option>Indiana</option>
<option>Iowa</option>
<option>Kansas</option>
<option>Kentucky</option>
<option>Louisiana</option>
<option>Maine</option>
<option>Maryland</option>
<option>Massachusetts</option>
<option>Michigan</option>
<option>Minnesota</option>
<option>Mississippi</option>
<option>Missouri</option>
<option>Montana</option>
<option>Nebraska</option>
<option>Nevada</option>
<option>New Hampshire</option>
<option>New Jersey</option>
<option>New Mexico</option>
<option>New York</option>
<option>North Carolina</option>
<option>North Dakota</option>
<option>Ohio</option>
<option>Oklahoma</option>
<option>Oregon</option>
<option>Pennsylvania</option>
<option>Rhode Island</option>
<option>South Carolina</option>
<option>South Dakota</option>
<option>Tennessee</option>
<option>Texas</option>
<option>Utah</option>
<option>Vermont</option>
<option>Virginia</option>
<option>Washington</option>
<option>West Virginia</option>
<option>Wisconsin</option>
<option>Wyoming</option>
</select></td>
</tr>
<tr>
<td class="lbl">Zip code:</td>
<td class="inp"><input type="text" class="writein" name="emCo2Zip" size="20" maxlength="20"></td>
</tr>
<tr>
<td class="lbl">Position held:</td>
<td class="inp"><input type="text" class="writein" name="emCo2PosHeld" size="60" maxlength="60"></td>
</tr>
<tr>
<td class="lbl">Name & Title of<br>
Immediate Supervisor</td>
<td class="inp"><input type="text" class="writein" name="emCo2NTofSup" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">starting date:</td>
<td>
<script>DateInput('start1', true, 'DD-MON-YYYY')</script>
</td>
</tr>
<td class="lbl">date left:</td>
<td><script>DateInput('left1', true, 'DD-MON-YYYY')</script></td>
</tr>
<td class="lbl">salary:</td>
<td class="inp"><input type="text" class="writein" name="emCo2Salary" size="20" maxlength="20"></td>
</tr>
<td class="sub_lbl">
<h4>Previous Employer</h4></td>
<td>(most recent first)
<tr>
<td class="lbl">Company Name:</td>
<td class="inp"><input type="text" class="writein" name="emCo3Name" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">Address</td>
<td class="inp"><input type="text" class="writein" name="emCo3Address" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">City</td>
<td class="inp"><input type="text" class="writein" name="emCo3City" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">State:</td>
<td><select name="emCo3State">
<option>Alabama</option>
<option>Alaska</option>
<option>Arizona</option>
<option>Arkansas</option>
<option>California</option>
<option>Colorado</option>
<option>Connecticut</option>
<option>Delaware</option>
<option>District of Columbia</option>
<option>Florida</option>
<option>Georgia</option>
<option>Hawaii</option>
<option>Idaho</option>
<option>Illinois</option>
<option>Indiana</option>
<option>Iowa</option>
<option>Kansas</option>
<option>Kentucky</option>
<option>Louisiana</option>
<option>Maine</option>
<option>Maryland</option>
<option>Massachusetts</option>
<option>Michigan</option>
<option>Minnesota</option>
<option>Mississippi</option>
<option>Missouri</option>
<option>Montana</option>
<option>Nebraska</option>
<option>Nevada</option>
<option>New Hampshire</option>
<option>New Jersey</option>
<option>New Mexico</option>
<option>New York</option>
<option>North Carolina</option>
<option>North Dakota</option>
<option>Ohio</option>
<option>Oklahoma</option>
<option>Oregon</option>
<option>Pennsylvania</option>
<option>Rhode Island</option>
<option>South Carolina</option>
<option>South Dakota</option>
<option>Tennessee</option>
<option>Texas</option>
<option>Utah</option>
<option>Vermont</option>
<option>Virginia</option>
<option>Washington</option>
<option>West Virginia</option>
<option>Wisconsin</option>
<option>Wyoming</option>
</select></td>
</tr>
<tr>
<td class="lbl">Zip code:</td>
<td class="inp"><input type="text" class="writein" name="emCo3Zip" size="20" maxlength="20"></td>
</tr>
<tr>
<td class="lbl">Position held:</td>
<td class="inp"><input type="text" class="writein" name="emCo3PosHeld" size="60" maxlength="60"></td>
</tr>
<tr>
<td class="lbl">Name & Title of<br>
Immediate Supervisor</td>
<td class="inp"><input type="text" class="writein" name="emCo3NTofSup" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">starting date:</td>
<td>
<script>DateInput('start1', true, 'DD-MON-YYYY')</script>
</td>
</tr>
<td class="lbl">date left:</td>
<td><script>DateInput('left1', true, 'DD-MON-YYYY')</script></td>
</tr>
<td class="lbl">salary:</td>
<td class="inp"><input type="text" class="writein" name="emCo3Salary" size="20" maxlength="20"></td>
</tr>
<td class="sub_lbl">
</tr>
<tr>
<tr height="50">
<td class="sub_lbl">Comments or Special Issues</td>
</tr>
<tr height="50">
<td height="50" colspan="6" bgcolor="white" class="inp"><textarea name="Comments" class="writein" cols="73" rows="4" wrap="physical"></textarea></td>
</tr>
<tr height="50">
<td><input type="submit" value="Send To Biehl & Biehl Collections" name="Submit"></td>
<td><input type="reset" value="Clear Form"></td>
</tr>
<tr height="22">
<td height="22" bgcolor="white" colspan="6">
<center>
</table>
</form>
</body>
</html>