<form name="User_add" id="ajax_form" action="?mod=USER&fnct=list&do=add&modifier=" method="POST">
<i>	<input name="react_to" id="react_to" value="?mod=USER&fnct=list&do=add&modifier=" type="hidden">
<input name="submitted_User_add" value="1" type="hidden">
</i><table><tbody><tr><td><strong>Name:</strong></td></tr>

<tr><td>First</td><td><input name="first" value="" type="text"></td><td>Last</td><td><input name="LAST" value="" type="text"></td></tr>
<tr><td>SSN</td><td><input value="" name="ssn" type="text"></td></tr>
<tr><td>Email</td><td><input name="email" value="none" type="text"></td><td>Role</td><td><select name="flags"><option value="1">Support Staff</option><option value="2">Social Worker</option><option value="3">Project Manager</option><option value="4">Office Administrator</option><option value="5">Regional Administrator</option><option value="6">Company Administrator</option><option value="7">Company Executive</option><option value="8">Technical Adminstrator</option><option value="9">Quality Assurace</option><option value="10">Developer</option><option value="11">Taazoo Executive</option>   </select></td></tr><tr><td>Office</td><td><select name="office"><option value="0">All Offices</option><option value="1">Taazoo</option><option value="2">DD Regional Center Program</option><option value="3">Cameron Park</option><option value="4">Santa Rosa</option><option value="5">South Lake Tahoe</option><option value="6">Jackson</option><option value="7">Stockton</option><option value="8">Demo Account HQ</option><option value="9">Sacramento</option><option value="10">HQ</option></select></td><td>Company</td><td><select name="company"><option value="1">Taazoo Development</option><option value="3">Demo Company</option><option value="4">Foster Family Service</option><option value="5">FFS Regional Center Program</option></select></td>
</tr><tr><td>Home Phone</td><td>(<input name="home1" size="3" value="" type="text">) <input name="home2" size="3" value="" type="text"> - <input name="home3" size="4" value="" type="text"></td><td>DL #</td><td><input name="dl" value="" type="text"></td></tr>

<tr><td>Cell Phone</td><td>(<input name="cell1" value="" size="3" type="text">) <input name="cell2" value="" size="3" type="text"> - <input name="cell3" value="" size="4" type="text"></td><td>DL State</td><td><select name="dl-state" value=""><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District Of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PA">Pennsylvania</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option></select></td></tr>

<tr><td><strong>Address</strong></td><td>&nbsp;</td><td>Exp Date</td><td><input name="exp" value="" type="text"></td></tr>
<tr><td>Street:</td><td><textarea name="street" cols="30" rows="3"></textarea></td></tr>
<tr><td>City:</td><td><input name="city" value="" type="text"></td></tr>

<tr><td>State:</td><td><input name="state" value="" type="text"></td></tr>
<tr><td>Zip:</td><td><input name="zip" value="" type="text"></td></tr>

<input value="1" name="portal" type="hidden"><tr><td><input onclick="javascript:submit_form_by_id('ajax_form', 'mod=USER&fnct=list&do=add&modifier=')" value="Add User" type="button"></td><td></td><i><input onclick="javascript:submit_form_by_id('ajax_form', 'mod=USER&another=1&fnct=add&do=add&modifier=')" value="Add Another" type="button"></i></tr></tbody></table>
</form>
<i> </i></div>
<i>									<br>&nbsp;<br>&nbsp;<br>&nbsp;<br>
</i></div>