|
Server : Apache/2.4.62 System : FreeBSD fbsdweb2.web.rcn.net 14.1-RELEASE FreeBSD 14.1-RELEASE releng/14.1-n267679-10e31f0946d8 GENERIC amd64 User : www ( 80) PHP Version : 8.3.8 Disable Function : NONE Directory : /domains/biehlweb/Old_FILES_09_08/ |
Upload File : |
<!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>Submit Claim</title>
<style type="text/css" media="all">
td.lbl {font-weight: bold; text-align: right;}
td.lbl_left {font-weight: bold; text-align: left;}
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.select {
font-size: 10pt;
color: #FF0000;
}
td {padding: 0.25em 1px;}
tr.required td.lbl {background: #FCC; border-left: 0.5em solid red;}
td.lbl {background: #;
background-color: #66CCFF;
border-left-width: 0.5em;
border-left-style: solid;
border-left-color: #0000FF;
}
td.lbl_left {
background-color: #66CCFF;
border-left-width: 0.5em;
border-left-style: solid;
border-left-color: #3300FF;
}
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="Submit_quote">
<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="submit a quote form" />
<table>
<tr>
<td class="sub_lbl"><h3>Client Information</h3></td>
</tr>
<tr class="required">
<td class="lbl">Biehl & Biehl Client #:</td>
<td class="inp"><input type="text" class="writein" name="clientNumber" size="24"></td>
</tr>
<tr class="required">
<td class="lbl">Company</td>
<td class="inp"><input type="text" class="writein" name="subCo" size="45"></td>
</tr>
<tr class="required">
<td class="lbl">Address</td>
<td class="inp"><input type="text" class="writein" name="subAddress" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">City</td>
<td class="inp"><input type="text" class="writein" name="subCity" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">State of residence:</td>
<td><select name="subState">
<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="subZip" size="20" maxlength="20"></td>
</tr>
<tr class="required">
<td class="lbl">E-mail:</td>
<td class="inp"><input type="text" class="writein" name="subEmail" size="60" maxlength="100"></td>
</tr>
<tr class="required">
<td class="lbl">Phone:</td>
<td class="inp"><input type="text" class="writein" name="subPhone" size="14" maxlength="14"></td>
</tr>
<tr class="required">
<td class="lbl">fax:</td>
<td class="inp"><input type="text" class="writein" name="subFax" size="14" maxlength="14"></td>
</tr>
<tr>
<td class="sub_lbl"><h3>Debtor Information</h3></td>
</tr>
<tr>
<td class="lbl">Company Name:</td>
<td class="inp"><input type="text" class="writein" name="deptCo" size="45"></td>
</tr>
<tr>
<td class="lbl">Owner/Principal:</td>
<td height="35" colspan="3" valign="top"><input type="text" class="writein" name="deptOwner" size="45"></td>
</tr>
<tr>
<td class="lbl">Contact Name:</td>
<td height="35" colspan="3" valign="top"><input type="text" class="writein" name="deptContactName" size="45"></td>
</tr>
<tr>
<td class="lbl">Address</td>
<td class="inp"><input type="text" class="writein" name="deptAddress" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">City</td>
<td class="inp"><input type="text" class="writein" name="deptCity" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">State of residence:</td>
<td><select name="deptState">
<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="deptZip" size="20" maxlength="20"></td>
</tr>
<tr>
<td class="lbl">E-mail:</td>
<td class="inp"><input type="text" class="writein" name="deptEmail" size="60" maxlength="100"></td>
</tr>
<tr>
<td class="lbl">Phone:</td>
<td class="inp"><input type="text" class="writein" name="depPhone" size="14" maxlength="14">
<tr>
<td class="lbl">fax:
<td class="inp"><input type="text" class="writein" name="deptFax" size="14" maxlength="14">
</tr>
<td class="lbl">Customer#:</td>
<td class="inp"><input type="text" class="writein" name="deptCustNumber" size="20"></td>
</tr>
<td class="lbl">Debtor's Bank:</td>
<td class="inp"><input type="text" class="writein" name="deptBank" size="34"></td>
<tr>
<td class="lbl">Bank Phone:
<td class="inp"><input type="text" class="writein" name="deptBankPhone" size="16"></td>
</tr>
<tr>
<td class="lbl">Debtor is a:</td><td>
<input type="radio" name="deptCorp" value="other">Corporation
<input type="radio" name="deptPartner" value="HS">Partnership
<input type="radio" name="deptSoloPro" value="BABS">Sole Proprietorship
</td>
<tr>
<td class="lbl">Amount of Debt:</td>
<td class="inp"><input type="text" class="writein" name="deptAmountOfDept" size="12"></td>
</tr>
<tr>
<td class="lbl">Date of oldest invoice:</td>
<td><script>DateInput('invoice', true, 'DD-MON-YYYY')</script></td>
<tr>
<td class="lbl">Date of Last Payment:</td>
<td>
<script>DateInput('payment', true, 'DD-MON-YYYY')</script>
</td>
<tr>
<td class="lbl">Did buyer receive goods?:</td>
<td>
<input type="radio" name="userEdu" value="other">Yes
<input type="radio" name="userEdu" value="HS">No</td>
</tr>
<tr>
<td class="lbl">Did buyer receive invoice?:</td>
<td>
<input type="radio" name="userEdu" value="other">Yes
<input type="radio" name="userEdu" value="HS">No</td>
</tr>
<tr>
<td class="lbl" valign="bottom">Please mark all that apply:</td>
<td><select name="All That Apply" size="3" multiple>
<option value="NSF_Checks">NSF Checks
<option value="Ignores_Demands">Ignores Demands
<option value="Unable_to_Contact">Unable to Contact
<option value="Valid_Dispute">Valid Dispute
<option value="Invalid_Dispute">Invalid Dispute
<option value="Broken_Promises">Broken Promises
</select></td>
</option></tr>
<tr>
<td></td><td class="select">(To select more than one: press CONTROL,or COMMAND for Mac, click with mouse)</td>
</tr>
<tr>
<td class="lbl">Others:<font size="-2">(Please Specify)</font></td>
<td><input type="text" class="writein" name="others" size="60"></td>
</tr>
<tr>
<td class="lbl" valign="bottom">I will be forwarding the following documents:</td>
<td>
<select name="Documents" size="3" multiple>
<option value="None">None
<option value="Statement_of_Account">Statement of Account
<option value="Invoices">Invoices
<option value="Purchase_Orders">Purchase Orders
<option value="Dishonored_Checks">Dishonored Checks
<option value="Correspondence">Correspondence
<option value="Credit_Report">Credit Report
<option value="Arbitration_Award">Arbitration Award
<option value="Personal_Guaranty">Personal Guaranty
<option value="Bill_of_Exchange">Original Bill of Exchange
<option value="Other">Other
</select></td>
</tr>
<tr>
<td class="lbl">Others:<font size="-2">(Please Specify)</font></td>
<td><input type="text" class="writein" name="others2" size="60"></td>
</tr>
<tr>
<td></td>
<td class="select">(To select more than one: press CONTROL,or COMMAND for Mac, click with mouse)</font></td>
</tr>
<tr>
<td class="lbl">Comments or Special Issues</td>
</tr>
<tr height="50">
<td height="50" colspan="6" bgcolor="white" class="inp"><textarea name="Comments" cols="73" rows="4" wrap="physical"></textarea></td>
</tr>
<tr height="22">
<td height="22" colspan="4">
<div align="center">
<h3>Please read the following before sending this form.</h3>
<p><font size="2">The above account is provided for the purpose of collection efforts. <br>
Biehl & Biehl Collection is authorized to deposit sums collected to its Trust Account <br>
and to select an attorney or agent to represent you in this matter, if required. <br>
You also certify that you have received, read and understood <br>
Biehl & Biehl Collection Fee Schedule applicable to this claim. </font></div>
</td>
</tr>
<tr height="50">
<td width="100" height="50" align="center" valign="bottom">
<input type="submit" name="mail" value="Please submit your claim"></td>
<td width="160" height="50" align="center" bgcolor="white" valign="bottom"><input type="reset"></td>
</tr>
</table>
</form>
</body>
</html>