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kiel367

my form

kiel367
Nov 6th, 2015
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  1. <div id="wb_Form1" style="position:absolute;width:610px;height:1346px;">
  2. <form name="Form1" method="post" action="" enctype="application/x-www-form-urlencoded" id="Form1">
  3. <div id="wb_Text2" style="position:absolute;left:5px;top:5px;width:602px;height:10px;z-index:83;text-align:left;">
  4. <span style="color:#000000;font-family:'Lucida Grande';font-size:12px;">Get A Quote</span></div>
  5. <div id="wb_Text3" style="position:absolute;left:5px;top:33px;width:602px;height:10px;z-index:84;text-align:left;">
  6. <span style="color:#000000;font-family:'Lucida Grande';font-size:12px;">Please Fill in the required details</span></div>
  7. <div id="wb_Text4" style="position:absolute;left:14px;top:79px;width:368px;height:10px;z-index:85;text-align:left;">
  8. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Name </span></div>
  9. <input type="text" id="Editbox1" style="position:absolute;left:15px;top:101px;width:358px;height:20px;line-height:20px;z-index:86;" name="element_1" value="">
  10. <div id="wb_Text5" style="position:absolute;left:14px;top:137px;width:368px;height:10px;z-index:87;text-align:left;">
  11. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Contact Number </span></div>
  12. <input type="text" id="Editbox2" style="position:absolute;left:15px;top:159px;width:181px;height:20px;line-height:20px;z-index:88;" name="element_2" value="">
  13. <div id="wb_Text6" style="position:absolute;left:14px;top:195px;width:368px;height:10px;z-index:89;text-align:left;">
  14. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Pickup Address </span></div>
  15. <input type="text" id="Editbox3" style="position:absolute;left:15px;top:217px;width:358px;height:20px;line-height:20px;z-index:90;" name="element_9_1" value="">
  16. <div id="wb_Text7" style="position:absolute;left:14px;top:239px;width:364px;height:12px;z-index:91;text-align:left;">
  17. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">Street Address</span></div>
  18. <input type="text" id="Editbox4" style="position:absolute;left:15px;top:261px;width:358px;height:20px;line-height:20px;z-index:92;" name="element_9_2" value="">
  19. <div id="wb_Text8" style="position:absolute;left:14px;top:283px;width:364px;height:12px;z-index:93;text-align:left;">
  20. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">Address Line 2</span></div>
  21. <input type="text" id="Editbox5" style="position:absolute;left:15px;top:305px;width:176px;height:20px;line-height:20px;z-index:94;" name="element_9_3" value="">
  22. <div id="wb_Text9" style="position:absolute;left:14px;top:327px;width:178px;height:12px;z-index:95;text-align:left;">
  23. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">City</span></div>
  24. <input type="text" id="Editbox6" style="position:absolute;left:201px;top:305px;width:176px;height:20px;line-height:20px;z-index:96;" name="element_9_4" value="">
  25. <div id="wb_Text10" style="position:absolute;left:200px;top:327px;width:178px;height:12px;z-index:97;text-align:left;">
  26. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">State / Province / Region</span></div>
  27. <input type="text" id="Editbox7" style="position:absolute;left:15px;top:349px;width:176px;height:20px;line-height:20px;z-index:98;" name="element_9_5" value="">
  28. <div id="wb_Text11" style="position:absolute;left:14px;top:371px;width:178px;height:12px;z-index:99;text-align:left;">
  29. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">Postal / Zip Code</span></div>
  30. <select name="element_9_6" size="1" id="Combobox1" style="position:absolute;left:202px;top:350px;width:176px;height:22px;z-index:100;">
  31. <option selected></option>
  32. <option value="Afghanistan">Afghanistan</option>
  33. <option value="Albania">Albania</option>
  34. <option value="Algeria">Algeria</option>
  35. <option value="Andorra">Andorra</option>
  36. <option value="Antigua and Barbuda">Antigua and Barbuda</option>
  37. <option value="Argentina">Argentina</option>
  38. <option value="Armenia">Armenia</option>
  39. <option value="Australia">Australia</option>
  40. <option value="Austria">Austria</option>
  41. <option value="Azerbaijan">Azerbaijan</option>
  42. <option value="Bahamas">Bahamas</option>
  43. <option value="Bahrain">Bahrain</option>
  44. <option value="Bangladesh">Bangladesh</option>
  45. <option value="Barbados">Barbados</option>
  46. <option value="Belarus">Belarus</option>
  47. <option value="Belgium">Belgium</option>
  48. <option value="Belize">Belize</option>
  49. <option value="Benin">Benin</option>
  50. <option value="Bhutan">Bhutan</option>
  51. <option value="Bolivia">Bolivia</option>
  52. <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
  53. <option value="Botswana">Botswana</option>
  54. <option value="Brazil">Brazil</option>
  55. <option value="Brunei">Brunei</option>
  56. <option value="Bulgaria">Bulgaria</option>
  57. <option value="Burkina Faso">Burkina Faso</option>
  58. <option value="Burundi">Burundi</option>
  59. <option value="Cambodia">Cambodia</option>
  60. <option value="Cameroon">Cameroon</option>
  61. <option value="Canada">Canada</option>
  62. <option value="Cape Verde">Cape Verde</option>
  63. <option value="Central African Republic">Central African Republic</option>
  64. <option value="Chad">Chad</option>
  65. <option value="Chile">Chile</option>
  66. <option value="China">China</option>
  67. <option value="Colombia">Colombia</option>
  68. <option value="Comoros">Comoros</option>
  69. <option value="Congo">Congo</option>
  70. <option value="Cook Islands and Niue">Cook Islands and Niue</option>
  71. <option value="Costa Rica">Costa Rica</option>
  72. <option value="Côte d'Ivoire">Côte d'Ivoire</option>
  73. <option value="Croatia">Croatia</option>
  74. <option value="Cuba">Cuba</option>
  75. <option value="Cyprus">Cyprus</option>
  76. <option value="Czech Republic">Czech Republic</option>
  77. <option value="Denmark">Denmark</option>
  78. <option value="Djibouti">Djibouti</option>
  79. <option value="Dominica">Dominica</option>
  80. <option value="Dominican Republic">Dominican Republic</option>
  81. <option value="East Timor">East Timor</option>
  82. <option value="Ecuador">Ecuador</option>
  83. <option value="Egypt">Egypt</option>
  84. <option value="El Salvador">El Salvador</option>
  85. <option value="Equatorial Guinea">Equatorial Guinea</option>
  86. <option value="Eritrea">Eritrea</option>
  87. <option value="Estonia">Estonia</option>
  88. <option value="Ethiopia">Ethiopia</option>
  89. <option value="Fiji">Fiji</option>
  90. <option value="Finland">Finland</option>
  91. <option value="France">France</option>
  92. <option value="Gabon">Gabon</option>
  93. <option value="Gambia">Gambia</option>
  94. <option value="Georgia">Georgia</option>
  95. <option value="Germany">Germany</option>
  96. <option value="Ghana">Ghana</option>
  97. <option value="Greece">Greece</option>
  98. <option value="Grenada">Grenada</option>
  99. <option value="Guatemala">Guatemala</option>
  100. <option value="Guinea">Guinea</option>
  101. <option value="Guinea-Bissau">Guinea-Bissau</option>
  102. <option value="Guyana">Guyana</option>
  103. <option value="Haiti">Haiti</option>
  104. <option value="Honduras">Honduras</option>
  105. <option value="Hong Kong">Hong Kong</option>
  106. <option value="Hungary">Hungary</option>
  107. <option value="Iceland">Iceland</option>
  108. <option value="India">India</option>
  109. <option value="Indonesia">Indonesia</option>
  110. <option value="Iran">Iran</option>
  111. <option value="Iraq">Iraq</option>
  112. <option value="Ireland">Ireland</option>
  113. <option value="Israel">Israel</option>
  114. <option value="Italy">Italy</option>
  115. <option value="Jamaica">Jamaica</option>
  116. <option value="Japan">Japan</option>
  117. <option value="Jordan">Jordan</option>
  118. <option value="Kazakhstan">Kazakhstan</option>
  119. <option value="Kenya">Kenya</option>
  120. <option value="Kiribati">Kiribati</option>
  121. <option value="North Korea">North Korea</option>
  122. <option value="South Korea">South Korea</option>
  123. <option value="Kuwait">Kuwait</option>
  124. <option value="Kyrgyzstan">Kyrgyzstan</option>
  125. <option value="Laos">Laos</option>
  126. <option value="Latvia">Latvia</option>
  127. <option value="Lebanon">Lebanon</option>
  128. <option value="Lesotho">Lesotho</option>
  129. <option value="Liberia">Liberia</option>
  130. <option value="Libya">Libya</option>
  131. <option value="Liechtenstein">Liechtenstein</option>
  132. <option value="Lithuania">Lithuania</option>
  133. <option value="Luxembourg">Luxembourg</option>
  134. <option value="Macedonia">Macedonia</option>
  135. <option value="Madagascar">Madagascar</option>
  136. <option value="Malawi">Malawi</option>
  137. <option value="Malaysia">Malaysia</option>
  138. <option value="Maldives">Maldives</option>
  139. <option value="Mali">Mali</option>
  140. <option value="Malta">Malta</option>
  141. <option value="Marshall Islands">Marshall Islands</option>
  142. <option value="Mauritania">Mauritania</option>
  143. <option value="Mauritius">Mauritius</option>
  144. <option value="Mexico">Mexico</option>
  145. <option value="Micronesia">Micronesia</option>
  146. <option value="Moldova">Moldova</option>
  147. <option value="Monaco">Monaco</option>
  148. <option value="Mongolia">Mongolia</option>
  149. <option value="Montenegro">Montenegro</option>
  150. <option value="Morocco">Morocco</option>
  151. <option value="Mozambique">Mozambique</option>
  152. <option value="Myanmar">Myanmar</option>
  153. <option value="Namibia">Namibia</option>
  154. <option value="Nauru">Nauru</option>
  155. <option value="Nepal">Nepal</option>
  156. <option value="Netherlands">Netherlands</option>
  157. <option value="New Zealand">New Zealand</option>
  158. <option value="Nicaragua">Nicaragua</option>
  159. <option value="Niger">Niger</option>
  160. <option value="Nigeria">Nigeria</option>
  161. <option value="Norway">Norway</option>
  162. <option value="Oman">Oman</option>
  163. <option value="Pakistan">Pakistan</option>
  164. <option value="Palau">Palau</option>
  165. <option value="Panama">Panama</option>
  166. <option value="Papua New Guinea">Papua New Guinea</option>
  167. <option value="Paraguay">Paraguay</option>
  168. <option value="Peru">Peru</option>
  169. <option value="Philippines">Philippines</option>
  170. <option value="Poland">Poland</option>
  171. <option value="Portugal">Portugal</option>
  172. <option value="Puerto Rico">Puerto Rico</option>
  173. <option value="Qatar">Qatar</option>
  174. <option value="Romania">Romania</option>
  175. <option value="Russia">Russia</option>
  176. <option value="Rwanda">Rwanda</option>
  177. <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
  178. <option value="Saint Lucia">Saint Lucia</option>
  179. <option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
  180. <option value="Samoa">Samoa</option>
  181. <option value="San Marino">San Marino</option>
  182. <option value="Sao Tome and Principe">Sao Tome and Principe</option>
  183. <option value="Saudi Arabia">Saudi Arabia</option>
  184. <option value="Senegal">Senegal</option>
  185. <option value="Serbia and Montenegro">Serbia and Montenegro</option>
  186. <option value="Seychelles">Seychelles</option>
  187. <option value="Sierra Leone">Sierra Leone</option>
  188. <option value="Singapore">Singapore</option>
  189. <option value="Slovakia">Slovakia</option>
  190. <option value="Slovenia">Slovenia</option>
  191. <option value="Solomon Islands">Solomon Islands</option>
  192. <option value="Somalia">Somalia</option>
  193. <option value="South Africa">South Africa</option>
  194. <option value="Spain">Spain</option>
  195. <option value="Sri Lanka">Sri Lanka</option>
  196. <option value="Sudan">Sudan</option>
  197. <option value="Suriname">Suriname</option>
  198. <option value="Swaziland">Swaziland</option>
  199. <option value="Sweden">Sweden</option>
  200. <option value="Switzerland">Switzerland</option>
  201. <option value="Syria">Syria</option>
  202. <option value="Taiwan">Taiwan</option>
  203. <option value="Tajikistan">Tajikistan</option>
  204. <option value="Tanzania">Tanzania</option>
  205. <option value="Thailand">Thailand</option>
  206. <option value="Togo">Togo</option>
  207. <option value="Tonga">Tonga</option>
  208. <option value="Trinidad and Tobago">Trinidad and Tobago</option>
  209. <option value="Tunisia">Tunisia</option>
  210. <option value="Turkey">Turkey</option>
  211. <option value="Turkmenistan">Turkmenistan</option>
  212. <option value="Tuvalu">Tuvalu</option>
  213. <option value="Uganda">Uganda</option>
  214. <option value="Ukraine">Ukraine</option>
  215. <option value="United Arab Emirates">United Arab Emirates</option>
  216. <option value="United Kingdom">United Kingdom</option>
  217. <option value="United States">United States</option>
  218. <option value="Uruguay">Uruguay</option>
  219. <option value="Uzbekistan">Uzbekistan</option>
  220. <option value="Vanuatu">Vanuatu</option>
  221. <option value="Vatican City">Vatican City</option>
  222. <option value="Venezuela">Venezuela</option>
  223. <option value="Vietnam">Vietnam</option>
  224. <option value="Yemen">Yemen</option>
  225. <option value="Zambia">Zambia</option>
  226. <option value="Zimbabwe">Zimbabwe</option>
  227. </select>
  228. <div id="wb_Text12" style="position:absolute;left:200px;top:371px;width:178px;height:12px;z-index:101;text-align:left;">
  229. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">Country</span></div>
  230. <div id="wb_Text13" style="position:absolute;left:14px;top:400px;width:368px;height:10px;z-index:102;text-align:left;">
  231. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Date Required </span></div>
  232. <div id="wb_Text14" style="position:absolute;left:14px;top:420px;width:54px;height:10px;z-index:103;text-align:left;">
  233. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> / MM</span></div>
  234. <input type="text" id="Editbox8" style="position:absolute;left:15px;top:422px;width:41px;height:20px;line-height:20px;z-index:104;" name="element_4_1" value="">
  235. <div id="wb_Text15" style="position:absolute;left:70px;top:420px;width:54px;height:10px;z-index:105;text-align:left;">
  236. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> / DD</span></div>
  237. <input type="text" id="Editbox9" style="position:absolute;left:71px;top:422px;width:41px;height:20px;line-height:20px;z-index:106;" name="element_4_2" value="">
  238. <div id="wb_Text16" style="position:absolute;left:126px;top:420px;width:57px;height:10px;z-index:107;text-align:left;">
  239. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> YYYY</span></div>
  240. <input type="text" id="Editbox10" style="position:absolute;left:127px;top:422px;width:53px;height:20px;line-height:20px;z-index:108;" name="element_4_3" value="">
  241. <div id="wb_Image2" style="position:absolute;left:185px;top:421px;width:16px;height:16px;z-index:109;">
  242. <img src="images/calendar_01.gif" id="Image2" alt="Pick a date."></div>
  243. <div id="wb_Text17" style="position:absolute;left:14px;top:473px;width:368px;height:10px;z-index:110;text-align:left;">
  244. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Time Required </span></div>
  245. <div id="wb_Text18" style="position:absolute;left:14px;top:493px;width:54px;height:10px;z-index:111;text-align:left;">
  246. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> : HH</span></div>
  247. <input type="text" id="Editbox11" style="position:absolute;left:15px;top:495px;width:41px;height:20px;line-height:20px;z-index:112;" name="element_3_1" value="">
  248. <div id="wb_Text19" style="position:absolute;left:70px;top:493px;width:54px;height:10px;z-index:113;text-align:left;">
  249. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> : MM</span></div>
  250. <input type="text" id="Editbox12" style="position:absolute;left:71px;top:495px;width:41px;height:20px;line-height:20px;z-index:114;" name="element_3_2" value="">
  251. <div id="wb_Text20" style="position:absolute;left:126px;top:493px;width:45px;height:10px;z-index:115;text-align:left;">
  252. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> SS</span></div>
  253. <input type="text" id="Editbox13" style="position:absolute;left:127px;top:495px;width:41px;height:20px;line-height:20px;z-index:116;" name="element_3_3" value="">
  254. <select name="element_3_4" size="1" id="Combobox2" style="position:absolute;left:175px;top:496px;width:53px;height:22px;z-index:117;">
  255. <option selected value="AM">AM</option>
  256. <option value="PM">PM</option>
  257. </select>
  258. <div id="wb_Text21" style="position:absolute;left:173px;top:517px;width:55px;height:12px;z-index:118;text-align:left;">
  259. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">AM/PM</span></div>
  260. <div id="wb_Text22" style="position:absolute;left:14px;top:546px;width:368px;height:10px;z-index:119;text-align:left;">
  261. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Destination Address </span></div>
  262. <input type="text" id="Editbox14" style="position:absolute;left:15px;top:568px;width:358px;height:20px;line-height:20px;z-index:120;" name="element_5" value="">
  263. <div id="wb_Text23" style="position:absolute;left:14px;top:604px;width:368px;height:10px;z-index:121;text-align:left;">
  264. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Postcode </span></div>
  265. <input type="text" id="Editbox15" style="position:absolute;left:15px;top:626px;width:181px;height:20px;line-height:20px;z-index:122;" name="element_6" value="">
  266. <div id="wb_Text24" style="position:absolute;left:14px;top:662px;width:368px;height:10px;z-index:123;text-align:left;">
  267. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Number Of Passengers </span></div>
  268. <select name="element_10" size="1" id="Combobox3" style="position:absolute;left:16px;top:685px;width:181px;height:22px;z-index:124;">
  269. <option selected></option>
  270. <option value="1">1</option>
  271. <option value="2">2</option>
  272. <option value="3">3</option>
  273. <option value="4">4</option>
  274. <option value="5">5</option>
  275. <option value="6">6</option>
  276. <option value="7">7</option>
  277. <option value="8">8</option>
  278. </select>
  279. <div id="wb_Text25" style="position:absolute;left:14px;top:720px;width:368px;height:10px;z-index:125;text-align:left;">
  280. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Children 0-3 years </span></div>
  281. <select name="element_12" size="1" id="Combobox4" style="position:absolute;left:16px;top:743px;width:181px;height:22px;z-index:126;">
  282. <option selected></option>
  283. <option value="1">1</option>
  284. <option value="2">2</option>
  285. <option value="3">3</option>
  286. <option value="4">4</option>
  287. <option value="5">5</option>
  288. <option value="6">6</option>
  289. <option value="7">7</option>
  290. <option value="8">8</option>
  291. </select>
  292. <div id="wb_Text26" style="position:absolute;left:14px;top:778px;width:368px;height:10px;z-index:127;text-align:left;">
  293. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Children 4-10 years </span></div>
  294. <select name="element_13" size="1" id="Combobox5" style="position:absolute;left:16px;top:801px;width:181px;height:22px;z-index:128;">
  295. <option selected></option>
  296. <option value="1">1</option>
  297. <option value="2">2</option>
  298. <option value="3">3</option>
  299. <option value="4">4</option>
  300. <option value="5">5</option>
  301. <option value="6">6</option>
  302. <option value="7">7</option>
  303. <option value="8">8</option>
  304. </select>
  305. <div id="wb_Text27" style="position:absolute;left:14px;top:836px;width:368px;height:10px;z-index:129;text-align:left;">
  306. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">One Way/Return </span></div>
  307. <div id="wb_Text28" style="position:absolute;left:14px;top:856px;width:79px;height:10px;z-index:130;text-align:left;">
  308. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> One Way&nbsp; Return</span></div>
  309. <input type="radio" id="RadioButton1" name="element_11" value="1" style="position:absolute;left:10px;top:862px;z-index:131;">
  310. <input type="radio" id="RadioButton2" name="element_11" value="2" style="position:absolute;left:10px;top:888px;z-index:132;">
  311. <div id="wb_Text29" style="position:absolute;left:14px;top:925px;width:368px;height:10px;z-index:133;text-align:left;">
  312. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Date Returning </span></div>
  313. <div id="wb_Text30" style="position:absolute;left:14px;top:945px;width:54px;height:10px;z-index:134;text-align:left;">
  314. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> / MM</span></div>
  315. <input type="text" id="Editbox16" style="position:absolute;left:15px;top:947px;width:41px;height:20px;line-height:20px;z-index:135;" name="element_7_1" value="">
  316. <div id="wb_Text31" style="position:absolute;left:70px;top:945px;width:54px;height:10px;z-index:136;text-align:left;">
  317. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> / DD</span></div>
  318. <input type="text" id="Editbox17" style="position:absolute;left:71px;top:947px;width:41px;height:20px;line-height:20px;z-index:137;" name="element_7_2" value="">
  319. <div id="wb_Text32" style="position:absolute;left:126px;top:945px;width:57px;height:10px;z-index:138;text-align:left;">
  320. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> YYYY</span></div>
  321. <input type="text" id="Editbox18" style="position:absolute;left:127px;top:947px;width:53px;height:20px;line-height:20px;z-index:139;" name="element_7_3" value="">
  322. <div id="wb_Image3" style="position:absolute;left:185px;top:946px;width:16px;height:16px;z-index:140;">
  323. <img src="images/calendar_01.gif" id="Image3" alt="Pick a date."></div>
  324. <div id="wb_Text33" style="position:absolute;left:14px;top:998px;width:368px;height:10px;z-index:141;text-align:left;">
  325. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Time OF Return Pickup </span></div>
  326. <div id="wb_Text34" style="position:absolute;left:14px;top:1018px;width:54px;height:10px;z-index:142;text-align:left;">
  327. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> : HH</span></div>
  328. <input type="text" id="Editbox19" style="position:absolute;left:15px;top:1020px;width:41px;height:20px;line-height:20px;z-index:143;" name="element_8_1" value="">
  329. <div id="wb_Text35" style="position:absolute;left:70px;top:1018px;width:54px;height:10px;z-index:144;text-align:left;">
  330. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> : MM</span></div>
  331. <input type="text" id="Editbox20" style="position:absolute;left:71px;top:1020px;width:41px;height:20px;line-height:20px;z-index:145;" name="element_8_2" value="">
  332. <div id="wb_Text36" style="position:absolute;left:126px;top:1018px;width:45px;height:10px;z-index:146;text-align:left;">
  333. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> SS</span></div>
  334. <input type="text" id="Editbox21" style="position:absolute;left:127px;top:1020px;width:41px;height:20px;line-height:20px;z-index:147;" name="element_8_3" value="">
  335. <select name="element_8_4" size="1" id="Combobox6" style="position:absolute;left:175px;top:1021px;width:53px;height:22px;z-index:148;">
  336. <option selected value="AM">AM</option>
  337. <option value="PM">PM</option>
  338. </select>
  339. <div id="wb_Text37" style="position:absolute;left:173px;top:1042px;width:55px;height:12px;z-index:149;text-align:left;">
  340. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;">AM/PM</span></div>
  341. <div id="wb_Text38" style="position:absolute;left:14px;top:1071px;width:368px;height:10px;z-index:150;text-align:left;">
  342. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Special Requirements </span></div>
  343. <div id="wb_Text39" style="position:absolute;left:14px;top:1091px;width:91px;height:20px;z-index:151;text-align:left;">
  344. <span style="color:#444444;font-family:'Lucida Grande';font-size:12px;"> None&nbsp; Wheelchair&nbsp; Child Seats</span></div>
  345. <input type="radio" id="RadioButton3" name="element_14" value="1" style="position:absolute;left:17px;top:1097px;z-index:152;">
  346. <input type="radio" id="RadioButton4" name="element_14" value="2" style="position:absolute;left:17px;top:1123px;z-index:153;">
  347. <input type="radio" id="RadioButton5" name="element_14" value="3" style="position:absolute;left:17px;top:1149px;z-index:154;">
  348. <div id="wb_Text40" style="position:absolute;left:14px;top:1186px;width:368px;height:10px;z-index:155;text-align:left;">
  349. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Number Of Small Cases </span></div>
  350. <select name="element_15" size="1" id="Combobox7" style="position:absolute;left:16px;top:1209px;width:91px;height:22px;z-index:156;">
  351. <option selected></option>
  352. <option value="1">1</option>
  353. <option value="2">2</option>
  354. <option value="3">3</option>
  355. <option value="4">4</option>
  356. <option value="5">5</option>
  357. <option value="6">6</option>
  358. <option value="7">7</option>
  359. <option value="8">8</option>
  360. </select>
  361. <div id="wb_Text41" style="position:absolute;left:14px;top:1244px;width:368px;height:10px;z-index:157;text-align:left;">
  362. <span style="color:#222222;font-family:'Lucida Grande';font-size:12px;">Number Of Large Cases </span></div>
  363. <select name="element_16" size="1" id="Combobox8" style="position:absolute;left:16px;top:1267px;width:91px;height:22px;z-index:158;">
  364. <option selected></option>
  365. <option value="1">1</option>
  366. <option value="2">2</option>
  367. <option value="3">3</option>
  368. <option value="4">4</option>
  369. <option value="5">5</option>
  370. <option value="6">6</option>
  371. <option value="7">7</option>
  372. <option value="8">8</option>
  373. </select>
  374. <input type="submit" id="Button1" name="submit" value="Submit" style="position:absolute;left:17px;top:1315px;width:69px;height:27px;z-index:159;">
  375. </form>
  376. </div>
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