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User : www ( 80)
PHP Version : 8.3.8
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Directory :  /domains/ventex/

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Current File : /domains/ventex/form.html
<!DOCTYPE HTML PUBLIC "-//W30//DTD W3 HTML 3.2//EN">
<HTML>
<HEAD>
<TITLE>Feedback Form</TITLE>
</HEAD>
<BODY Background="graphics/canvas1.jpg">
<H1 ALIGN=CENTER><i>Feedback Form</i></H1>
<HR>
<B><FORM ACTION="http://www.ventexfabrics.com/cgi-bin/formmail.pl" METHOD=POST>
<INPUT TYPE="hidden" NAME="redirect" VALUE="http://www.ventexfabrics.com/thanks.html">
<PRE>
Last Name: <INPUT TYPE="text" NAME="LastName" SIZE=40>
First Name:<INPUT TYPE="text" NAME="FirstName" SIZE=40>
Company:   <INPUT TYPE="text" NAME="Company" SIZE=40>

Address 1: <INPUT TYPE="text" NAME="Address1" SIZE=40>
Address 2: <INPUT TYPE="text" NAME="Address2" SIZE=40>
City:      <INPUT TYPE="text" NAME="City" SIZE=20>
State:     <INPUT TYPE="text" NAME="State" SIZE=3 maxlength=2>&nbsp;ZIP:<INPUT TYPE="text" NAME="zip" SIZE=11>

Phone #:   <INPUT TYPE="text" NAME="Phone">
FAX #:     <INPUT TYPE="text" NAME="FAX">
e-mail:    <INPUT TYPE="text" NAME="email">
<br />
Area of interest:
           <INPUT TYPE="checkbox" VALUE="interested" NAME="Integrity_Fire_barrier">Integrity30&reg; Firebarrier &nbsp;
           <INPUT TYPE="checkbox" VALUE="interested" NAME="Sprungold_Fire_barrier">Spungold&reg; Residential Firebarrier &nbsp;
           <INPUT TYPE="checkbox" VALUE="interested" NAME="Healthcare_Fabrics">Healthcare Fabrics &nbsp;
           <INPUT TYPE="checkbox" VALUE="interested" NAME="Firebarrier_Furniture">Activ(TM) Firebarrier for Furniture &nbsp;
           <INPUT TYPE="checkbox" VALUE="interested" NAME="Dust_Mite_barrier">Dust Mite Barrier &nbsp;
           <INPUT TYPE="checkbox" VALUE="interested" NAME="other_Areas">other &nbsp;<INPUT TYPE="text" NAME="otherarea" VALUE="(please specify)">
<br />
Want our Brochure?  <INPUT TYPE="radio" NAME="Brochure" VALUE="yes" CHECKED> yes <INPUT TYPE="radio" NAME="Brochure" VALUE="no"> no<br />

Comments:  
           <TEXTAREA NAME="Comments" ROWS=4 COLS=40>
</TEXTAREA><br />

            <INPUT TYPE="submit" VALUE="Submit Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<INPUT TYPE="reset" VALUE="Reset Form"><br /></B>
</PRE>

<INPUT TYPE="hidden" NAME="subject" VALUE="Ventex feedback form">
<INPUT TYPE="hidden" NAME="recipient" VALUE="[email protected],[email protected]">
</FORM></B>

<HR>



<center><a href="contact.html"><IMG SRC="graphics/goback.jpeg" ALT="[goback]" HEIGHT=31 WIDTH=90 BORDER=0></a></center>

<center><small>Copyright� 2015 Ventex, Inc. All rights reserved.</small></center>


</BODY>

</HTML>

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