<?php
/**
 * Page Template
 *
 * This is the standard page template.
 *
 * @package DolanJenner
 * @subpackage Template
 */

$meta_title = '';
$meta_description = '';
$meta_keywords = '';
$page_context = 'page';
$page_title = 'Contact Us';

require_once('includes/header.php'); // Loads the header.php template. ?>

		<div id="content" class="site-content hfeed">

			<article class="hentry page">
				<?php if($page_title) : ?><h1 class="page-title entry-title"><?php echo $page_title; ?></h1><?php endif; ?>
				<div class="entry-content">
					<p>For immediate assistance, please call us at 800.833.4237</p>
					<p><span class="required">*</span> Indicates a required field</p>
					<form action="https://www.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST" onSubmit="return validation(this);">
                <table border="0" cellpadding="0" style="font-family:verdana; font-size:12px;">
                <tbody>
                <tr>
                <td width="120px"><label for="first_name">First Name <span class="required">*</span></label></td>
                <td width="200px"><input  id="first_name" maxlength="40" name="first_name" size="26.5" type="text" /></td>
                <td width="75px"><label for="last_name">Last Name <span class="required">*</span></label></td>
                <td><input  id="last_name" maxlength="80" name="last_name" size="26.5" type="text" /></td>
                </tr>
                <tr>
                <td><label for="email">Email <span class="required">*</span></label></td>
                <td><input  id="email" maxlength="80" name="email" size="26.5" type="text" /></td>
                <td><label for="phone">Phone</label></td>
                <td><input  id="phone" maxlength="40" name="phone" size="26.5" type="text" /></td>
                </tr>
                <tr>
                <td><label for="company">Company <span class="required">*</span></label></td>
                <td colspan="3"><input  id="company" maxlength="40" name="company" size="26.5" type="text" /></td>
                </tr>
                <tr>
                <td rowspan="2" valign="top"><label for="street">Address</label></td>
                <td rowspan="2"><textarea name="street" rows="3"></textarea></td>
                <td><label for="city">City/Province</label></td>
                <td><input  id="city" maxlength="40" name="city" size="26.5" type="text" /></td>
                </tr>
                <tr>
                <td><label for="state">State <span class="required">*</span></label></td>
                <td><input  id="state" maxlength="20" name="state" size="26.5" type="text" /></td>
                </tr>
                <tr>
                <td><label for="country">Country <span class="required">*</span></label></td>
                <td colspan="3"><input  id="country" maxlength="40" name="country" size="26.5" type="text" /></td>
                </tr>
                <tr>
                <td>Product Interest:</td>
                <td colspan="3"><select name="00N30000008QccZ" size="4" multiple="multiple"  id="00N30000008QccZ" title="Product Interest" rows="10">

<option value="DJ ACCESSORIES">Accessories</option>
<option value="DJ CONTROLS">Dolan-Jenner Controls</option>
<option value="DJ FIBER OPTICS CUSTOM">Fiber Optics - Custom</option>
<option value="DJ FIBER OPTICS STANDARD">Fiber Optics - Standard</option>
<option value="DJ MACHINE VISION ACCESSORY">Machine Vision Accessories</option>
<option value="DJ MACHINE VISION FIBER OPTIC">Machine Vision Fiber Optics</option>
<option value="DJ MACHINE VISION LIGHT SOURCE">Machine Vision Light Sources</option>
<option value="DJ MICROSCOPY ACCESSORY">Microscopy Accessories</option>
<option value="DJ MICROSCOPY FIBER OPTIC">Microscopy Fiber Optics</option>
<option value="DJ MICROSCOPY LIGHT SOURCE">Microscopy Light Sources</option>
</select><br>
<span style="font-size: 10px;">(Hold Ctrl to Select Multiple Products)</span></td>
                </tr>
                <tr>
                <td>Comments/Questions:</td>
                <td colspan="3"><textarea name="00N30000008QLEFEA4" cols="75" rows="10" wrap="soft"  id="00N30000008QLEFEA4" type="text"></textarea></td>
                </tr>
                <tr>
                <td></td>
                <td colspan="3"><input type="submit" name="submit" value="Contact Us"></td>
                </tr>
                </tbody>
                </table>
<input type="hidden" name="oid" value="00D30000000oUGY">
<input type="hidden" name="retURL" value="http://dolan-jenner.com/Condolan/Thank_you.htm">
<input type="hidden"  id="lead_source" name="lead_source" value="Web" />
<input type="hidden"  id="00N30000008QLE0" name="00N30000008QLE0" value="Dolan Jenner Web Request" />
<input type="hidden"  id="rating" name="rating" value="Hot" />
<input type="hidden"  id="Campaign_ID" name="Campaign_ID" value="701a0000001vTC2" />
<input type="hidden"  id="member_status" name="member_status" value="Responded" />
<input type="hidden"  id="00N30000008QM0C" name="00N30000008QM0C" value="Fiber Optics" />
</form>

				</div><!-- .entry-content -->
			</article><!-- .hentry -->

		</div><!-- #content .hfeed -->

<?php require_once('includes/footer.php'); // Loads the footer.php template. ?>