<style type="text/css">
	.contactForm fieldset { width:620px; border:1px solid #990000; }
	.contactForm legend { font-weight:bold; background-color:#990000; color:#FFFFFF; padding:3px; border:1px solid #990000; margin-left:25px; }
	.contactForm .formQuestion { padding:5px; }
	.contactForm .formQuestion label { width:250px; float:left; text-align:left; }
	.contactForm .formQuestion input { width:355px; }
	.contactForm .formQuestion select { width:360px; }
	.contactForm .submitForm { padding:5px; text-align:right; }
	.contactForm .formHint { padding:5px; margin:5px 0 0 0; border:1px dashed #000000; color:#990000; text-align:center; }
	.contactForm .formDisclaimer { padding:5px; margin:0 0 5px 0; border:1px dashed #FF0000; color:#FF0000; text-align:center; font-size:10px; float:left; }
</style>

<script type="text/javascript" src="/global/js/form_validation.js"></script>
<script type="text/javascript">
	function validate_form() {
		document.contactForm.from.value = '"'+document.contactForm.contactName.value+'" <'+document.contactForm.emailAddress.value+'>';
		return checkForm();
	}
</script>

<center>
<form action="/dotCMS/submitWebForm" method="post" name="contactForm" class="contactForm" onSubmit="return validate_form();">
  <input type="hidden" name="from" value="DisabilitiesInquiryNOREPLY@edinboro.edu" />
  <input type="hidden" name="order" value="contactName,emailAddress,phoneNumber,message" />
  <input type="hidden" name="prettyOrder" value="Full Name,Email Address,Phone Number,Message" />
  <input type="hidden" name="subject" value="Disabilities Conference Inquiry" />
  <input type="hidden" name="html" value="1" />
  <input type="hidden" name="returnUrl" value="/empowerment/contact_thanks.dot" />
  <input type="hidden" name="errorUrl" value="/empowerment/contact.dot?error=1" />

  <fieldset><legend>Contact Us</legend>

  <div class="formQuestion" id="intro_text">
    <p>Your questions about the 2010 Annual Disabilities Conference are very important to us. Please complete the following form to receive more information.</p>
  </div>

  <div class="formQuestion">
		<label for="contactName">Full Name: (required)</label>
		<input type="text" value="$!request.getParameter('contactName')" name="contactName" required="text" pretty="Full Name" />
	</div>

  <div class="formQuestion">
		<label for="emailAddress">Email Address: (required)</label>
		<input type="text" value="$!request.getParameter('emailAddress')" name="emailAddress" required="email" pretty="Email Address" />
	</div>

  <div class="formQuestion">
		<label for="phoneNumber">Phone Number: (required)</label>
		<input type="text" value="$!request.getParameter('phoneNumber')" name="phoneNumber" required="text" pretty="Phone Number" />
	</div>

	<div class="formQuestion">
		<label for="sendTo">Inquiry Type:</label>
		<select id="sendTo" name="to" required="radio" pretty="Topic">
			  ##set($encryptedEmail = $crypt.crypt("peterson@edinboro.edu"))
  			##<option value="$!{encryptedEmail}" selected="selected">General</option>
        ##set($encryptedEmail = $crypt.crypt("jboykin@edinboro.edu"))
  			##<option value="$!{encryptedEmail}">On-Campus Housing</option>
        ##set($encryptedEmail = $crypt.crypt("mcconnell@edinboro.edu"))
  			##<option value="$!{encryptedEmail}">Special Accomodations</option>
        ##set($encryptedEmail = $crypt.crypt("jacqui.barnett@edinboro.edu"))
  			##<option value="$!{encryptedEmail}">Program Content</option>

  			<option value="peterson@edinboro.edu" selected="selected">General</option>
  			<option value="jboykin@edinboro.edu">On-Campus Housing</option>
  			<option value="mcconnell@edinboro.edu">Special Accomodations</option>
  			<option value="jacqui.barnett@edinboro.edu">Program Content</option>
		</select>
	</div>


	<div class="formQuestion">
		<label for="message">Message:</label><br />
		<textarea name="message" cols="73" rows="5" required="text" pretty="Message">$!request.getParameter('message')</textarea>
	</div>

	<div class="submitForm">
		<input type="submit" value="Send Inquiry" />
	</div>
  </fieldset>
</form>
</center>