document.write("<title>ContactForm</title>\n");
document.write("<scr"+"ipt language=javascr"+"ipt>\n");
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document.write("<form  method=POST action=\"http://forms.uia.net/cgi-bin/csFormbuilder/csFormbuilder.cgi\" name=\"form_1148\"  >\n");
document.write("<input type=hidden name=form-id value=\"1148\">\n");
document.write("<input type=hidden name=command value=\"mailform\">\n");
document.write("<link rel=\"stylesheet\" type=\"text/css\" href=\"http://forms.uia.net/cgi-scr"+"ipt/csFormbuilder/forms/AFX_PhoneForm.css\">\n");
document.write("<table border=\"0\" cellspacing=\"0\" cellpadding=\"3\">\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*Name:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Name\"  size=\"30\"  > <!-- tr ph 0--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*Email:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email\"  size=\"30\"  > <!-- tr ph 1--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"right\" >*Confirm Email:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Conform_Email\"  size=\"30\"  > <!-- tr ph 2--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*Phone:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone\"  size=\"20\"  > <!-- tr ph 3--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >Alternate:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"AlternatePhone\"  size=\"20\"  > <!-- tr ph 4--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >Best time to call:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"BestTime_from\"  size=\"10\"  > <!-- tr ph 5--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >to</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"BestTime_to\"  size=\"10\"  > <!-- tr ph 6--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" >Best day to call: </td><td align=left valign=top nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Mon\"></td><td class=\"textLabel\">Mon</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Tue\"></td><td class=\"textLabel\">Tue</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Wed\"></td><td class=\"textLabel\">Wed</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Thu\"></td><td class=\"textLabel\">Thu</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Fri\"></td><td class=\"textLabel\">Fri</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Sat\"></td><td class=\"textLabel\">Sat</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"BestDay\" value=\"Sun\"></td><td class=\"textLabel\">Sun</td>\n");
document.write("</tr></table>\n");
document.write(" <!-- tr ph 7--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" >This issue is: </td><td align=left valign=top nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"Issue\" value=\"URGENT!\"></td><td class=\"textLabel\">URGENT!</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"Issue\" value=\"Important\"></td><td class=\"textLabel\">Important</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"Issue\" value=\"As sson as you get some time\"></td><td class=\"textLabel\">As sson as you get some time</td>\n");
document.write("</tr></table>\n");
document.write(" <!-- tr ph 8--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*Nature of Problem:</td><td align=left valign=top nowrap class=\"textLabel\"><textarea  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" name=\"Problem\"  rows=\"5\" cols=\"50\"  ></textarea>   <!-- tr ph 9--></td></tr>\n");
document.write("<tr><td colspan=2 align=\"left\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=submit value=\"Submit\"></td></tr>\n");
document.write("</table>\n");
document.write("</form>\n");