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Oct 5th, 2015
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  1. <div id="emf-container-outer">
  2. <div id="emf-container" >
  3. <div id="emf-logo"><a >EmailMeForm</a></div>
  4. <div class="emf-error-message" style='display:none'></div>
  5. <form id="emf-form" target="_self" class="topLabel" enctype="multipart/form-data" method="post" action="https://www.emailmeform.com/builder/form/xxxxxxxxxxx"><div id="emf-form-instruction" class="emf-head-widget">
  6. <div id="emf-form-title" class="emf-bold">Request Pricing</div><div id="emf-form-description">This form is to request pricing information for special products on our store. Due to contract agreements some products are not allowed to have displayed prices. Please contact us directly for pricing information.</div>
  7. </div>
  8. <ul>
  9. <li id="emf-li-0" class="emf-li-field emf-field-new_name data_container emf-li-half-width ">
  10. <label class="emf-label-desc" for="element_0">Name</label>
  11. <div class="emf-div-field"><span style="width:60px">
  12. <input class="validate[optional]" style="width:100%" value=""
  13. id="element_2" name="element_2" type="text" />
  14. <label for="element_2" class="emf-bottom-label emf-text-center">First</label>
  15. </span><span style="width:100px">
  16. <input class="validate[optional]" style="width:100%" value=""
  17. id="element_3" name="element_3" type="text" />
  18. <label for="element_3" class="emf-bottom-label emf-text-center">Last</label>
  19. </span></div>
  20. <div class="emf-clear"></div>
  21. </li><li id="emf-li-7" class="emf-li-field emf-field-text data_container emf-li-half-width ">
  22. <label class="emf-label-desc" for="element_7">Business</label>
  23. <div class="emf-div-field"><input id="element_7" name="element_7" value="" size="30" type="text"
  24.  
  25. class="validate[optional]"/></div>
  26. <div class="emf-clear"></div>
  27. </li><li id="emf-li-8" class="emf-li-field emf-field-email data_container ">
  28. <label class="emf-label-desc" for="element_8">Email <span>*</span></label>
  29. <div class="emf-div-field"><input id="element_8" name="element_8"
  30. class="validate[required,custom[email]]"
  31. value="" size="30" type="text" /></div>
  32. <div class="emf-clear"></div>
  33. </li><li id="emf-li-9" class="emf-li-field emf-field-phone data_container ">
  34. <label class="emf-label-desc" for="element_9">Phone</label>
  35. <div class="emf-div-field">
  36. <span>
  37. <input maxlength="3" value="" id="element_9_1" name="element_9[]" type="text" class="emf-input-w30 validate[optional,custom[onlyNumber],length[3,3]]" />
  38. <label for="element_9_1" class="emf-bottom-label">###</label>
  39. </span><span class="emf-sep">-</span><span>
  40. <input maxlength="3" value="" id="element_9_2" name="element_9[]" type="text" class="emf-input-w30 validate[optional,custom[onlyNumber],length[3,3]]" />
  41. <label for="element_9_2" class="emf-bottom-label">###</label>
  42. </span><span class="emf-sep">-</span><span>
  43. <input maxlength="4" value="" id="element_9_3" name="element_9[]" type="text" class="emf-input-w40 validate[optional,custom[onlyNumber],length[4,4]]" />
  44. <label for="element_9_3" class="emf-bottom-label">####</label>
  45. </span></div>
  46. <div class="emf-clear"></div>
  47. </li><li id="emf-li-10" class="emf-li-field emf-field-select data_container emf-li-half-width ">
  48. <label class="emf-label-desc" for="element_10">Preferred Contact Method</label>
  49. <div class="emf-div-field"><select id="element_10" name="element_10"
  50. class="validate[optional]" my_choice_order_type=""><option value="" selected="selected" my_order_property="first">Email</option><option value="Phone" >Phone</option></select></div>
  51. <div class="emf-clear"></div>
  52. </li><li id="emf-li-11" class="emf-li-field emf-field-text data_container ">
  53. <label class="emf-label-desc" for="element_11">Product Information Requested <span>*</span></label>
  54. <div class="emf-div-field"><input id="element_11" name="element_11" value="" size="30" type="text"
  55.  
  56. class="validate[required]"/></div>
  57. <div class="emf-clear"></div>
  58. </li><li id="emf-li-12" class="emf-li-field emf-field-textarea data_container ">
  59. <label class="emf-label-desc" for="element_12">Additional Notes</label>
  60. <div class="emf-div-field"><textarea id="element_12" name="element_12" cols="45" rows="10"
  61. class="validate[optional]"></textarea></div>
  62. <div class="emf-clear"></div>
  63. </li>
  64. <li id="emf-li-recaptcha" style="display:none;">
  65. <div>
  66. <script type="text/javascript">
  67. var RecaptchaOptions = {
  68. theme: 'custom',
  69. custom_theme_widget: 'emf-recaptcha_widget'
  70. };
  71. </script>
  72. <div id='emf-recaptcha_widget' style='display:none'>
  73. <div id='recaptcha_image'></div>
  74. <div id='recaptcha_controls'>
  75. <a title='Get a new challenge' href="javascript:Recaptcha.reload()"><img src='//assets.emailmeform.com/images/recaptcha_refresh.png?xxxxxxxxxxxx' alt='Get a new challenge'></a><!--
  76. --><a title='Get an audio challenge' href="javascript:Recaptcha.switch_type('audio')" class='recaptcha_only_if_image'><img src='//assets.emailmeform.com/images/recaptcha_audio.png?RU1GLTAyLTI1LTQ5MjZjMzE%3D' alt='Get an audio challenge'></a><!--
  77. --><a title='Get a visual challenge' href="javascript:Recaptcha.switch_type('image')" class='recaptcha_only_if_audio'><img src='//assets.emailmeform.com/images/recaptcha_image.png?RU1GLTAyLTI1LTQ5MjZjMzE%3D' alt='Get a visual challenge'></a><!--
  78. --><a title='Help' href="javascript:Recaptcha.showhelp()"><img alt='Help' src='//assets.emailmeform.com/images/recaptcha_help.png?RU1GLTAyLTI1LTQ5MjZjMzE%3D'></a>
  79. </div>
  80. <img id='recaptcha_logo' style='' src='https://www.google.com/recaptcha/api/img/clean/logo.png'>
  81. <input type='text' id='recaptcha_response_field' name='recaptcha_response_field'
  82. placeholder='Type the text'>
  83. </div>
  84. <script type="text/javascript" src="https://www.google.com/recaptcha/api/challenge?k=xxxxxxxxxxxxxxxxxxxx"></script>
  85. <noscript>
  86. <iframe src="https://www.google.com/recaptcha/api/noscript?k=xxxxxxxxxxxxxxxx" height="300" width="500" frameborder="0"></iframe><br/>
  87. <textarea name="recaptcha_challenge_field" rows="3" cols="40"></textarea>
  88. <input type="hidden" name="recaptcha_response_field" value="manual_challenge"/>
  89. </noscript></div>
  90. </li>
  91. <li id="emf-li-post-button" class="left">
  92. <input value="Submit" type="submit" onmouseover="return true;"/>
  93. </li>
  94. </ul>
  95. <input name="element_counts" value="13" type="hidden" />
  96. <input name="embed" value="forms" type="hidden" />
  97. </form>
  98. </div><img id="emf-form-shadows" src="//assets.emailmeform.com/images/themes/bottom.png?RU1GLTAyLTI1LTQ5MjZjMzE%3D"></div>
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