olivebranchms/obms_r2/em_info.php3.old

<?php // the email requst form
header("Pragma: no-cache");
header("Content-type: text/html");
$basetarget="main";
include("html/head.std");
?>

<table border=0>
  <TR>
    <TD valign="top" width="98%">
      <P align="center"><FONT face="Arial"><SMALL><BR></SMALL><EM><BIG>Request For More Information</BIG></EM></FONT></P>
      <FORM method="POST" action="_vti_bin/shtml.dll/req.htm" webbot-action="--WEBBOT-SELF--">
        <INPUT TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><DIV align="center">
        <CENTER>
        <TABLE border="0" width="80%">
          <TR>
            <TD colspan="3" valign="top">
              <SMALL><FONT face="Arial">I have looked at the Chamber's website but I need more information. I need more information on:</FONT></SMALL>
            </TD>
          </TR>
          <TR>
            <TD valign="top">
              <STRONG><FONT face="Arial"><SMALL><BR>Visiting or Moving to your area</SMALL><BR></FONT></STRONG>
              <P>
              <SMALL><FONT face="Arial">
                <INPUT type="checkbox" name="MovingArea" value="Need Printed Map">I need a printed map of the area.<BR>
                <INPUT type="checkbox" name="MovingArea" value="Need Newcomers Guide">I need a printed Newcomer's Guide for the area
                </FONT></SMALL>
            </TD>
            <TD valign="top"></TD>
            <TD valign="top">
              <STRONG><SMALL><FONT face="Arial">
              <BR>Starting a Business or Moving a Business to your area</FONT></SMALL></STRONG>
              <P><SMALL><FONT face="Arial">
                <INPUT type="checkbox" name="StartingBusiness" value="Need Site And Building Info">
                  I need more information about sites and buildings.<BR>
                  <INPUT type="checkbox" name="StartingBusiness" value="Need Personal Contact">
                  I need someone to contact me for specific answers to my questions.
              </FONT></SMALL></STRONG>
            </TD>
          </TR>
          <TR>
            <TD valign="top"></TD>
            <TD valign="top"></TD>
            <TD valign="top"></TD>
          </TR>
        </TABLE>
        <TABLE border="0" width="80%">
          <TR>
            <TD align="right">
              <STRONG><SMALL><FONT face="Arial"><BR>Name</FONT></SMALL></STRONG>
            </TD>
            <TD>
              <SMALL><FONT face="Arial">
              <BR><INPUT type="text" name="Name" size="30">
              </FONT></SMALL>
            </TD>
          </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Title</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="Title" size="30"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Company</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="Company" size="30"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Address</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="Address" size="30"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">City</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="City" size="20"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">State</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="State" size="20"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Zip</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="Zip" size="15"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Phone</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="Phone" size="15"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Fax</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="Fax" size="15"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"><STRONG><SMALL><FONT face="Arial">Email Address</FONT></SMALL></STRONG></TD>
           <TD><SMALL><FONT face="Arial"><INPUT type="text" name="EmailAddress" size="20"></FONT></SMALL></TD>
         </TR>
         <TR>
           <TD align="right"></TD>
           <TD></TD>
         </TR>
         <TR>
           <TD valign="top" align="right"></TD>
           <TD valign="top">
             <SMALL><FONT face="Arial">
               <INPUT type="submit" value="Submit" name="B1"> <INPUT type="reset" value="Reset" name="B2"><BR><BR>
             </FONT></SMALL>
           </TD>
         </TR>
        </TABLE>
        </CENTER>
      </FORM>
    </td>
  </tr>
</table>
<?php
include("html/tail.std");
?>