You can not select more than 25 topics
Topics must start with a letter or number, can include dashes ('-') and can be up to 35 characters long.
28 lines
1.2 KiB
28 lines
1.2 KiB
<?php // info request input form
|
|
?>
|
|
<table border=0 cellpadding=4 cellspacing=0>
|
|
<form method="post" action="reply.php3">
|
|
<tr><th colspan=4>Request For More Information</th></tr>
|
|
<tr><td class=label>Name:</td>
|
|
<td class=data><input type="text" name="name" size=20></td>
|
|
<td class=label>Title:</td>
|
|
<td class=data><input type="text" name="title" size=20></td></tr>
|
|
<tr><td class=label>Address:</td>
|
|
<td class=data><input type="text" name="address" size=20></td>
|
|
<td class=label>Company:</td>
|
|
<td class=data><input type="text" name="company" size=20></td></tr>
|
|
<tr><td class=label>City:</td>
|
|
<td class=data><input type="text" name="city" size=20></td>
|
|
<td class=label>Phone:</td>
|
|
<td class=data><input type="text" name="phone" size=20></td></tr>
|
|
<tr><td class=label>State:</td>
|
|
<td class=data><input type="text" name="state" size=20></td>
|
|
<td class=label>Fax:</td>
|
|
<td class=data><input type="text" name="fax" size=20></td></tr>
|
|
<tr><td class=label>Zip:</td>
|
|
<td class=data><input type="text" name="zip" size=20></td>
|
|
<td class=label>Email:</td>
|
|
<td class=data><input type="text" name="email" size=20></td></tr>
|
|
<tr><td colspan=4 class=dropped>
|
|
<input type="reset"><input type="submit"></td></tr>
|
|
</table>
|