<div style="margin-bottom: 12px;">Please provide the following information.<span id="cookies_enabled"></span></div>
        <form action="*" class="web_form" name="leadForm" method="POST">
        <div style="display: block;" class="no-loading">
            <br /><br />
            <label>First Name:</label>  <input name="fname" id="fname" size="20" maxlength="40" style="width: 150px;"  checkmax="2" required="1" real_name="First Name" type="text">
            <br /><br />
            <label>Last Name:</label>   <input name="lname" id="lname" size="20" maxlength="40" style="width: 150px;"  checkmax="2" required="1" real_name="Last Name" type="text">
            <br /><br />
            <label>E-mail:</label>  <input real_name="Email Address" name="email" id="email" size="20" maxlength="80" style="width: 150px;" class="bodyblack required-field valid-email" required="1" type="text">
            <br /><br />
            <label>Phone:</label>   <input name="phone" id="phone" size="20" maxlength="40" style="width: 150px;" required="1" real_name="Phone" type="text">
            <br /><br />
            <label>Company:</label> <input name="company" id="company" size="20" maxlength="80" style="width: 150px;"  checkmax="2" required="1" real_name="Company Name" type="text">
            <br /><br />
            <label>Web site:</label>    <input name="URL" id="URL" size="20" maxlength="80" style="width: 150px;" required="1" real_name="Corporate Website" type="text">
            <br /><br />
            <label>Zip Code:</label>    <input name="Zip" id="Zip" size="20" maxlength="80" style="width: 150px;" required="1" real_name="Zip" type="text">
            <br /><br />
            <label>Department/Function:</label>
                <select name="job_function" id="job_function" style="width: 150px;"  required="1" real_name="Department">
                  <option value="" selected="selected">Select One</option>
                  <option value="*">*</option>
                  <option value="*">*</option>
                  <option value="*">*</option>
                  <option value="Other">Other</option>
                </select>
            <br /><br />
            <label>Job Title:</label>
                <select name="job_rank" id="job_rank" style="width: 150px;" class="required-field" required="1" real_name="Job Title">
                  <option value="" selected="selected">Select One</option>
                  <option value="*">*</option>
                  <option value="*">*</option>
                  <option value="*">*</option>
                  <option value="Other">Other</option>
                </select>
            <br /><br />

            <h3> I am interested in (check all that apply):</h3>
                <label><input style="border: medium none ;" name="" id="" value="" type="checkbox">Email</label>
                <label><input style="border: medium none ;" name="" id="" value="" type="checkbox">CRM</label>
                <label><input style="border: medium none ;" name="" id="" value="" type="checkbox">Sharepoint</label>
                <label><input style="border: medium none ;" name="" id="" value="" type="checkbox">ERP</label>
                <label><input style="border: medium none ;" name="" id="" value="" type="checkbox">Implementation and Migration</label>
                <label><input style="border: medium none ;" name="" id="" value="" type="checkbox">Custom Development</label>

            <br /><br />

            <label>Purchase Time Frame:</label>
            <select name="timeframe" style="width: 150px;"  required="1" real_name="timeframe">
                  <option value="*" selected="selected">Select One</option>
                  <option value="2">2-4 weeks</option>
                  <option value="4">4-12 weeks</option>
                  <option value="12">12-24 weeks</option>
                  <option value="24">24-48 weeks</option>
                  <option value="uncertain">uncertain</option>
            </select>
            <br />
            <br />

            <label>Industry:</label>
            <select name="industry" id="industry" style="width: 150px;"  required="1" real_name="Industry">
                  <option value="" selected="selected">Select One</option>
                  <option value="Agency or Consultant">Agency or Consultant</option>
                  <option value="Automotive">Automotive</option>
                  <option value="Business Services">Business Services</option>
                  <option value="Consumer Products">Consumer Products</option>
                  <option value="Education">Education</option>
                  <option value="Entertainment">Entertainment</option>
                  <option value="Financial Services">Financial Services</option>
                  <option value="Government">Government</option>
                  <option value="Health Care">Health Care     </option>
                  <option value="High Tech">High Tech</option>
                  <option value="Insurance">Insurance</option>
                  <option value="Internet">Internet</option>
                  <option value="Manufacturing">Manufacturing</option>
                  <option value="Media">Media</option>
                  <option value="Non-Profit">Non-Profit</option>
                  <option value="Real Estate">Real Estate</option>
                  <option value="Retail">Retail</option>
                  <option value="Telecommunications">Telecommunications</option>
                  <option value="Travel & Hospitality">Travel & Hospitality</option>
                  <option value="Other">Other</option>
            </select>

                <br /> <br />
                <label>Comments:</label><br />
                <textarea cols="30" rows="5" name="questions" id="questions" style="width: 150px;"></textarea>
                <br />


                </div>
        </div>
        </form>