"<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>",