<fieldset class="contact-us">

<label>Select a Contact: *<br />
[select* recipient include_blank "Customer Service | <customerservice@amerex-fire.com>" "Sales |<sales@amerex-fire.com>" "Systems Sales |<systemsales@amerex-fire.com>" "International Sales |<internationalsales@amerex-fire.com>" "Government Sales |<governmentsales@amerex-fire.com>" "Military Sales |<militarysales@amerex-fire.com>" "Catalog Request |<catalogrequest@amerex-fire.com>" "Fire Extinguisher Emergency |<emergency@amerex-fire.com>" "Special Hazards |<specialhazards@amerex-fire.com>" "Technical Information |<technicalinfo@amerex-fire.com>" "Quality Assurance |<quality@amerex-fire.com>" "MSDS Information |<msdsinfo@amerex-fire.com>" "Human Resources |<resources@amerex-fire.com>" "Website Issues |<jflayhart@infomedia.com>"]</label>

<label>Your Email Address *<br />
[email* email class:text]</label>

<label class="subject">Subject *<br />
[text* subject class:text]</label>

<label>Company/Name *<br />
[text* company class:text]</label>

<label>Address<br />
[text address class:text]</label>

<label>City<br />
[text city class:text]</label>

<label class="state">State<br />
[select state include_blank "Alabama" "Alaska" "Arizona" "Arkansas" "California" "Colorado" "Connecticut" "Delaware" "Florida" "Georgia" "Hawaii" "Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine" "Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri" "Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New York" "North Carolina" "North Dakota" "Ohio" "Oklahoma" "Oregon" "Pennsylvania" "Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah" "Vermont" "Virginia" "Washington" "West Virginia" "Wisconsin" "Wyoming"]</label>

<label>Zip<br />
[text zip class:text]</label>

<label>Phone<br />
[text phone class:text]</label>

<label class="message">Your Message *<br />
[textarea* message]</label>

</fieldset>

[captchac captcha-230 size:l]
Please enter the characters you see in the image above:
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<div class="buttons">[submit class:submit "Send"]</div>