[include css('credit-forms.css')];

[html-page set-title("Credit Application")];


<div id="product-container">
	<h2>Credit Application</h2>
	<h3>All fields are mandatory on this form.</h3>

	<div style='display: [var error-display];' class='error-group'>
		[var error-message];
	</div>

	<form method='post' action="" id="credit-application" style='display: [var form-display];'>
		<input type="hidden" name="submitted" value="1">
		<input type="hidden" name="formType" value="credit-application">
		<input type="hidden" name="language" value="English">
		<table>
			<tbody>
				<tr>
					<td class="title">
						<label for='business'>Legal Name of Business:</label>
					</td>
					<td class="field">
						<input type="text" name='business' id='business' class='std-field' value="[var business];">
					</td>
					
					<td class="title">
						<label for='phone'>Phone:</label>
					</td>
					<td class="field">
						<input type="text" name='phone' id='phone' class='std-field' value="[var phone];">
					</td>
				</tr>

				<tr>

					<td class="title">
						<label for='email'>Email:</label>
					</td>
					<td class="field">
						<input type="text" name='from' id='email' class='std-field' value="[var from];">
					</td>


					<td class="title">
						<label for='fax'>Fax:</label>
					</td>
					<td class="field">
						<input type="text" name='fax' id='fax' class='std-field' value="[var fax];">
					</td>
					
					<td class="title">
						<label for='billing-address'>Billing Address:</label>
					</td>
					<td class="field">
						<input type="text" name='billing-address' id='billing-address' class='std-field' value="[var billing-address];">
					</td>
				</tr>

				<tr>

					<td class="title">
						<label for='city'>City:</label>
					</td>
					<td class="field">
						<input type="text" name='billing-city' id='city' class='std-field' value="[var billing-city];">
					</td>

					<td class="title">
						<label for='state'>State:</label>
					</td>
					<td class="field">
						<select name="billing-state" id='state' title='State' class='std-select'>
							[htmlpage select-options('[var billing-state];', '', [var state-option-params];)];
						</select>
					</td>
					<td class="title">
						<label for='zip'>Zip:</label>
					</td>
					<td class="field">
						<input type="text" name='billing-zip' id='zip' class='std-field' value="[var billing-zip];">
					</td>
					
				</tr>
				
				<tr>
					
					<td class='title'>
						<label for='international'>International Countries:</label>
					</td>
					<td class="field">
						<input type="text" name='international' id='international' class='std-field' value="[var international];">
					</td>
					
					<td class="title">
						<label for='zip'>Resale or Taxable:</label>
					</td>
					<td class="field">
						<select name="resale" id='resale' title='resale' class='std-select'>
							[htmlpage select-options('[var own-lease-business];', 'Select', 'Resale', 'Taxable')];
						</select>
					</td>

					<td class="title">
						<label for='resale-number'>Resale Number:</label>
					</td>
					<td class="field">
						<input name="resale-number" id='resale-number' title='resale-number' class='std-field' value="[var resale-number];">
					</td>
				</tr>

				<tr>
					<td class="title">
						<label for='delivery-address'>Delivery Address:</label>
					</td>
					<td class="field">
						<input type="text" name='delivery-address' id='delivery-address' class='std-field' value="[var delivery-address];">
					</td>
					<td class="title">
						<label for='delivery-city'>City:</label>
					</td>
					<td class="field">
						<input type="text" name='delivery-city' id='delivery-city' class='std-field'>
					</td>
					<td class="title">
						<label for='delivery-state'>State:</label>
					</td>
					<td class="field">
						<select name="delivery-state" id='delivery-state' title='delivery-state' class='std-select'>
							[htmlpage select-options('[var delivery-state];', '', [var state-option-params];)];
						</select>
					</td>
				</tr>
				<tr>
					<td class="title">
						<label for='delivery-zip'>Zip:</label>
					</td>
					<td class="field">
						<input type="text" name='delivery-zip' id='delivery-zip' class='std-field' value="[var delivery-zip];">
					</td>
					<td class='title'>
						<label for='delivery-international'>Delivery-International Country:</label>
					</td>
					<td class="field">
						<input type="text" name='delivery-international' id='delivery-international' class='std-field' value="[var delivery-international];">
					</td>
					<td class="title">
						<label for='delivery-phone'>Delivery Phone#:</label>
					</td>
					<td class="field">
						<input type="text" name='delivery-phone' id='delivery-phone' class='std-field' value="[var delivery-phone];">
					</td>
				</tr>

				<tr>
					<td class="title">
						<label for='business-type'>Business Type:</label>
					</td>
					<td class="field">
						<select name="business-type" id='business-type' title='business-type' class='std-select'>
							[htmlpage select-options('[var own-lease-business];', 'Select', 'Sole Proprietorship', 'Partnership', 'Corporation')];
						</select>
					</td>
					<td class="title">
						<label for='state-inc'>State Incorporated:</label>
					</td>
					<td class="field">
						<select name="state-inc" id='state-inc' title='state-inc' class='std-select'>
							[htmlpage select-options('[var state-inc];', '', [var state-option-params];)];`
						</select>
					</td>
				</tr>

				<tr>
					<td class="title">
						<label for='owners-partners'>Owners or <br/> Partner's Name:</label>
					</td>
					<td class="field">
						<input type="text" name='owners-partners' id='owners-partners' class='std-field' value="[var owners-partners];">
					</td>
					<td class="title">
						<label for='date-started'>Date Business Started:</label>
					</td>
					<td class="field">
						<input type="text" name='date-started' id='date-started' class='std-field' value="[var date-started];">
					</td>
				</tr>
			</tbody>
		</table>

		<table>
			<tbody>
				<tr>
					<td >
						<h3>If Corporation:</h3>
					</td>
				</tr>
				<tr>
					<td class="title">
						<label for='president'>President:</label>
					</td>
					<td class="field">
						<input type="text" name='president' id='president' class='std-field' value="[var president];">
					</td>
					<td class="title">
						<label for='vice-president'> Vice President:</label>
					</td>
					<td class="field">
						<input type="text" name='vice-president' id='vice-president' class='std-field' value="[var vice-president];">
					</td>
				</tr>
				<tr>
					<td class="title">
						<label for='secretary'>Secretary:</label>
					</td>
					<td class="field">
						<input type="text" name='secretary' id='secretary' class='std-field' value="[var secretary];">
					</td>
					<td class="title">
						<label for='treasurer'> Treasurer:</label>
					</td>
					<td class="field">
						<input type="text" name='treasurer' id='treasurer' class='std-field' value="[var treasurer];">
					</td>
				</tr>
				<tr>
					<td class="title">
						<label for='nature-business'>Nature of Business:</label>
					</td>
					<td class="field">
						<input type="text" name='nature-business' id='nature-business' class='std-field' value="[var nature-business];">
					</td>
					<td class="title">
						<label for='present-location'>How Long at Present Location:</label>
					</td>
					<td class="field">
						<input type="test" name='present-location' id='present-location' class='std-field' value="[var present-location];">
					</td>
				</tr>
				<tr>
					<td class="title">
						<label for='own-lease-business'>Do you own or lease the facilities your business occupies?</label>
					</td>
					<td class="field">
						<select name="own-lease-business" id='own-lease-businessc' title='own-lease-business' class='std-select'>
							[htmlpage select-options('[var own-lease-business];', 'Select', 'Own', 'Lease')];
						</select>
					</td>
					<td class="title">
						<label for='financial'>Are you willing to provide a recent financial statement if requested?</label>
					</td>
					<td class="field">
						<select name="financial" id='financial' title='financial' class='std-select'>
							[htmlpage select-options('[var financial];', 'Select', 'Yes', 'No')];
						</select>
					</td>
				</tr>
				<!--
				<tr>
					<td class="title">
						<label for='credit'>Amount of Credit Desired</label>
					</td>
					<td class="field">
						<input name="credit" id='credit' title='credit' class='std-field'>
					</td>

					<td class="title">
						<label for='net'>Net Terms Desired</label>
					</td>
					<td class="field">
						<input name="net" id='net' title='net terms' class='std-field'>
					</td>
				</tr>
			</tbody>
		</table>


		<h3>References:</h3>
		<p>
			We hereby make credit application to your company.  We understand and agree to comply with all the terms
			and conditions specified herein.  (a)  All accounts are due and payable according to the terms noted on
			each invoice.  Accounts not paid within the terms reflected on the invoices will be subject to a service
			charge of 1 ?% (one and one-half percent) per month on the unpaid balance past due.  Corresponding Annual
			Percentage Rate (APR) of 18% or maximum legal interest rate.  (b)  In the event that your check is not honored
			due to NSF, we will charge you an additional service charge of $15.00.
		</p>

		<p>
			<label for='social'>Applicant's social security number of Federal Tax ID number:</label>
			<input name="social" id='social' title='social security' class='std-field'>
		</p>
		<p>
			<label class='std-option' for='confirm'>I hereby affirm that I am the person stated above and am authorized to submit the information in this for to KPI Companies, Inc.</label>
			<input type='checkbox' name='confirm' id='confirm'>
		</p>

		<h3>Credit References</h3>
			<table>
				<tbody>
					<tr>
						<td class="title">
							<label for='company'>Company:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='company'>Contact Name:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='account'>Account#:</label>
						</td>
						<td class="field">
							<input type="account" name='account' id='account' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='phone'>Phone:</label>
						</td>
						<td class="field">
							<input type="text" name='phone' id='phone' class='std-field'>
						</td>


						<td class="title">
							<label for='fax'>Fax:</label>
						</td>
						<td class="field">
							<input type="text" name='fax' id='fax' class='std-field'>
						</td>

						<td class="title">
							<label for='email'>Email:</label>
						</td>
						<td class="field">
							<input type="text" name='email' id='email' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='address'>Address:</label>
						</td>
						<td class="field">
							<input type="text" name='address' id='address' class='std-field'>
						</td>
						<td class="title">
							<label for='city'>City:</label>
						</td>
						<td class="field">
							<input type="city" name='city' id='city' class='std-field'>
						</td>

						<td class="title">
							<label for='state'>State:</label>
						</td>
						<td class="field">
								<select name="state" id='state' title='State' class='std-select'>
									<option value="" title="Choose a  state" ></option>
									<option value="AL" title="Alabama" >Alabama</option>
									<option value="AK" title="Alaska" >Alaska</option>
									<option value="AZ" title="Arizona" >Arizona</option>
									<option value="AR" title="Arkansas" >Arkansas</option>
									<option value="CA" title="California" >California</option>
									<option value="CO" title="Colorado" >Colorado</option>

									<option value="CT" title="Connecticut" >Connecticut</option>
									<option value="DE" title="Delaware" >Delaware</option>
									<option value="DC" title="District Of Columbia" >District Of Columbia</option>
									<option value="FL" title="Florida" >Florida</option>
									<option value="GA" title="Georgia" >Georgia</option>
									<option value="HI" title="Hawaii" >Hawaii</option>

									<option value="ID" title="Idaho" >Idaho</option>
									<option value="IL" title="Illinois" >Illinois</option>
									<option value="IN" title="Indiana" >Indiana</option>
									<option value="IA" title="Iowa" >Iowa</option>
									<option value="KS" title="Kansas" >Kansas</option>
									<option value="KY" title="Kentucky" >Kentucky</option>

									<option value="LA" title="Louisiana" >Louisiana</option>
									<option value="ME" title="Maine" >Maine</option>
									<option value="MD" title="Maryland" >Maryland</option>
									<option value="MA" title="Massachusetts" >Massachusetts</option>
									<option value="MI" title="Michigan" >Michigan</option>
									<option value="MN" title="Minnesota" >Minnesota</option>

									<option value="MS" title="Mississippi" >Mississippi</option>
									<option value="MO" title="Missouri" >Missouri</option>
									<option value="MT" title="Montana" >Montana</option>
									<option value="NE" title="Nebraska" >Nebraska</option>
									<option value="NV" title="Nevada" >Nevada</option>
									<option value="NH" title="New Hampshire" >New Hampshire</option>

									<option value="NJ" title="New Jersey" >New Jersey</option>
									<option value="NM" title="New Mexico" >New Mexico</option>
									<option value="NY" title="New York" >New York</option>
									<option value="NC" title="North Carolina" >North Carolina</option>
									<option value="ND" title="North Dakota" >North Dakota</option>
									<option value="OH" title="Ohio" >Ohio</option>

									<option value="OK" title="Oklahoma" >Oklahoma</option>
									<option value="OR" title="Oregon" >Oregon</option>
									<option value="PA" title="Pennsylvania" >Pennsylvania</option>
									<option value="RI" title="Rhode Island" >Rhode Island</option>
									<option value="SC" title="South Carolina" >South Carolina</option>
									<option value="SD" title="South Dakota" >South Dakota</option>

									<option value="TN" title="Tennessee" >Tennessee</option>
									<option value="TX" title="Texas" >Texas</option>
									<option value="UT" title="Utah" >Utah</option>
									<option value="VT" title="Vermont" >Vermont</option>
									<option value="VA" title="Virginia" >Virginia</option>
									<option value="WA" title="Washington" >Washington</option>

									<option value="WV" title="West Virginia" >West Virginia</option>
									<option value="WI" title="Wisconsin" >Wisconsin</option>
									<option value="WY" title="Wyoming" >Wyoming</option>
								</select>
						</td>
					</tr>
					<tr>
						<td class="title">
							<label for='zip'>Zip:</label>
						</td>
						<td class="field">
							<input type="text" name='zip' id='zip' class='std-field'>
						</td>
					</tr>
				</tbody>
			</table>

						<table>
				<tbody>
					<tr>
						<td class="title">
							<label for='company'>Company:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='company'>Contact Name:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='account'>Account#:</label>
						</td>
						<td class="field">
							<input type="account" name='account' id='account' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='phone'>Phone:</label>
						</td>
						<td class="field">
							<input type="text" name='phone' id='phone' class='std-field'>
						</td>


						<td class="title">
							<label for='fax'>Fax:</label>
						</td>
						<td class="field">
							<input type="text" name='fax' id='fax' class='std-field'>
						</td>

						<td class="title">
							<label for='email'>Email:</label>
						</td>
						<td class="field">
							<input type="text" name='email' id='email' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='address'>Address:</label>
						</td>
						<td class="field">
							<input type="text" name='address' id='address' class='std-field'>
						</td>
						<td class="title">
							<label for='city'>City:</label>
						</td>
						<td class="field">
							<input type="city" name='city' id='city' class='std-field'>
						</td>

						<td class="title">
							<label for='state'>State:</label>
						</td>
						<td class="field">
								<select name="state" id='state' title='State' class='std-select'>
									<option value="" title="Choose a  state" ></option>
									<option value="AL" title="Alabama" >Alabama</option>
									<option value="AK" title="Alaska" >Alaska</option>
									<option value="AZ" title="Arizona" >Arizona</option>
									<option value="AR" title="Arkansas" >Arkansas</option>
									<option value="CA" title="California" >California</option>
									<option value="CO" title="Colorado" >Colorado</option>

									<option value="CT" title="Connecticut" >Connecticut</option>
									<option value="DE" title="Delaware" >Delaware</option>
									<option value="DC" title="District Of Columbia" >District Of Columbia</option>
									<option value="FL" title="Florida" >Florida</option>
									<option value="GA" title="Georgia" >Georgia</option>
									<option value="HI" title="Hawaii" >Hawaii</option>

									<option value="ID" title="Idaho" >Idaho</option>
									<option value="IL" title="Illinois" >Illinois</option>
									<option value="IN" title="Indiana" >Indiana</option>
									<option value="IA" title="Iowa" >Iowa</option>
									<option value="KS" title="Kansas" >Kansas</option>
									<option value="KY" title="Kentucky" >Kentucky</option>

									<option value="LA" title="Louisiana" >Louisiana</option>
									<option value="ME" title="Maine" >Maine</option>
									<option value="MD" title="Maryland" >Maryland</option>
									<option value="MA" title="Massachusetts" >Massachusetts</option>
									<option value="MI" title="Michigan" >Michigan</option>
									<option value="MN" title="Minnesota" >Minnesota</option>

									<option value="MS" title="Mississippi" >Mississippi</option>
									<option value="MO" title="Missouri" >Missouri</option>
									<option value="MT" title="Montana" >Montana</option>
									<option value="NE" title="Nebraska" >Nebraska</option>
									<option value="NV" title="Nevada" >Nevada</option>
									<option value="NH" title="New Hampshire" >New Hampshire</option>

									<option value="NJ" title="New Jersey" >New Jersey</option>
									<option value="NM" title="New Mexico" >New Mexico</option>
									<option value="NY" title="New York" >New York</option>
									<option value="NC" title="North Carolina" >North Carolina</option>
									<option value="ND" title="North Dakota" >North Dakota</option>
									<option value="OH" title="Ohio" >Ohio</option>

									<option value="OK" title="Oklahoma" >Oklahoma</option>
									<option value="OR" title="Oregon" >Oregon</option>
									<option value="PA" title="Pennsylvania" >Pennsylvania</option>
									<option value="RI" title="Rhode Island" >Rhode Island</option>
									<option value="SC" title="South Carolina" >South Carolina</option>
									<option value="SD" title="South Dakota" >South Dakota</option>

									<option value="TN" title="Tennessee" >Tennessee</option>
									<option value="TX" title="Texas" >Texas</option>
									<option value="UT" title="Utah" >Utah</option>
									<option value="VT" title="Vermont" >Vermont</option>
									<option value="VA" title="Virginia" >Virginia</option>
									<option value="WA" title="Washington" >Washington</option>

									<option value="WV" title="West Virginia" >West Virginia</option>
									<option value="WI" title="Wisconsin" >Wisconsin</option>
									<option value="WY" title="Wyoming" >Wyoming</option>
								</select>
						</td>
					</tr>
					<tr>
						<td class="title">
							<label for='zip'>Zip:</label>
						</td>
						<td class="field">
							<input type="text" name='zip' id='zip' class='std-field'>
						</td>
					</tr>
				</tbody>
			</table>

						<table>
				<tbody>
					<tr>
						<td class="title">
							<label for='company'>Company:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='company'>Contact Name:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='account'>Account#:</label>
						</td>
						<td class="field">
							<input type="account" name='account' id='account' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='phone'>Phone:</label>
						</td>
						<td class="field">
							<input type="text" name='phone' id='phone' class='std-field'>
						</td>


						<td class="title">
							<label for='fax'>Fax:</label>
						</td>
						<td class="field">
							<input type="text" name='fax' id='fax' class='std-field'>
						</td>

						<td class="title">
							<label for='email'>Email:</label>
						</td>
						<td class="field">
							<input type="text" name='email' id='email' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='address'>Address:</label>
						</td>
						<td class="field">
							<input type="text" name='address' id='address' class='std-field'>
						</td>
						<td class="title">
							<label for='city'>City:</label>
						</td>
						<td class="field">
							<input type="city" name='city' id='city' class='std-field'>
						</td>

						<td class="title">
							<label for='state'>State:</label>
						</td>
						<td class="field">
								<select name="state" id='state' title='State' class='std-select'>
									<option value="" title="Choose a  state" ></option>
									<option value="AL" title="Alabama" >Alabama</option>
									<option value="AK" title="Alaska" >Alaska</option>
									<option value="AZ" title="Arizona" >Arizona</option>
									<option value="AR" title="Arkansas" >Arkansas</option>
									<option value="CA" title="California" >California</option>
									<option value="CO" title="Colorado" >Colorado</option>

									<option value="CT" title="Connecticut" >Connecticut</option>
									<option value="DE" title="Delaware" >Delaware</option>
									<option value="DC" title="District Of Columbia" >District Of Columbia</option>
									<option value="FL" title="Florida" >Florida</option>
									<option value="GA" title="Georgia" >Georgia</option>
									<option value="HI" title="Hawaii" >Hawaii</option>

									<option value="ID" title="Idaho" >Idaho</option>
									<option value="IL" title="Illinois" >Illinois</option>
									<option value="IN" title="Indiana" >Indiana</option>
									<option value="IA" title="Iowa" >Iowa</option>
									<option value="KS" title="Kansas" >Kansas</option>
									<option value="KY" title="Kentucky" >Kentucky</option>

									<option value="LA" title="Louisiana" >Louisiana</option>
									<option value="ME" title="Maine" >Maine</option>
									<option value="MD" title="Maryland" >Maryland</option>
									<option value="MA" title="Massachusetts" >Massachusetts</option>
									<option value="MI" title="Michigan" >Michigan</option>
									<option value="MN" title="Minnesota" >Minnesota</option>

									<option value="MS" title="Mississippi" >Mississippi</option>
									<option value="MO" title="Missouri" >Missouri</option>
									<option value="MT" title="Montana" >Montana</option>
									<option value="NE" title="Nebraska" >Nebraska</option>
									<option value="NV" title="Nevada" >Nevada</option>
									<option value="NH" title="New Hampshire" >New Hampshire</option>

									<option value="NJ" title="New Jersey" >New Jersey</option>
									<option value="NM" title="New Mexico" >New Mexico</option>
									<option value="NY" title="New York" >New York</option>
									<option value="NC" title="North Carolina" >North Carolina</option>
									<option value="ND" title="North Dakota" >North Dakota</option>
									<option value="OH" title="Ohio" >Ohio</option>

									<option value="OK" title="Oklahoma" >Oklahoma</option>
									<option value="OR" title="Oregon" >Oregon</option>
									<option value="PA" title="Pennsylvania" >Pennsylvania</option>
									<option value="RI" title="Rhode Island" >Rhode Island</option>
									<option value="SC" title="South Carolina" >South Carolina</option>
									<option value="SD" title="South Dakota" >South Dakota</option>

									<option value="TN" title="Tennessee" >Tennessee</option>
									<option value="TX" title="Texas" >Texas</option>
									<option value="UT" title="Utah" >Utah</option>
									<option value="VT" title="Vermont" >Vermont</option>
									<option value="VA" title="Virginia" >Virginia</option>
									<option value="WA" title="Washington" >Washington</option>

									<option value="WV" title="West Virginia" >West Virginia</option>
									<option value="WI" title="Wisconsin" >Wisconsin</option>
									<option value="WY" title="Wyoming" >Wyoming</option>
								</select>
						</td>
					</tr>
					<tr>
						<td class="title">
							<label for='zip'>Zip:</label>
						</td>
						<td class="field">
							<input type="text" name='zip' id='zip' class='std-field'>
						</td>
					</tr>
				</tbody>
			</table>

						<table>
				<tbody>
					<tr>
						<td class="title">
							<label for='company'>Company:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='company'>Contact Name:</label>
						</td>
						<td class="field">
							<input type="text" name='company' id='company' class='std-field'>
						</td>
						<td class="title">
							<label for='account'>Account#:</label>
						</td>
						<td class="field">
							<input type="account" name='account' id='account' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='phone'>Phone:</label>
						</td>
						<td class="field">
							<input type="text" name='phone' id='phone' class='std-field'>
						</td>


						<td class="title">
							<label for='fax'>Fax:</label>
						</td>
						<td class="field">
							<input type="text" name='fax' id='fax' class='std-field'>
						</td>

						<td class="title">
							<label for='email'>Email:</label>
						</td>
						<td class="field">
							<input type="text" name='email' id='email' class='std-field'>
						</td>
					</tr>

					<tr>
						<td class="title">
							<label for='address'>Address:</label>
						</td>
						<td class="field">
							<input type="text" name='address' id='address' class='std-field'>
						</td>
						<td class="title">
							<label for='city'>City:</label>
						</td>
						<td class="field">
							<input type="city" name='city' id='city' class='std-field'>
						</td>

						<td class="title">
							<label for='state'>State:</label>
						</td>
						<td class="field">
								<select name="state" id='state' title='State' class='std-select'>
									<option value="" title="Choose a  state" ></option>
									<option value="AL" title="Alabama" >Alabama</option>
									<option value="AK" title="Alaska" >Alaska</option>
									<option value="AZ" title="Arizona" >Arizona</option>
									<option value="AR" title="Arkansas" >Arkansas</option>
									<option value="CA" title="California" >California</option>
									<option value="CO" title="Colorado" >Colorado</option>

									<option value="CT" title="Connecticut" >Connecticut</option>
									<option value="DE" title="Delaware" >Delaware</option>
									<option value="DC" title="District Of Columbia" >District Of Columbia</option>
									<option value="FL" title="Florida" >Florida</option>
									<option value="GA" title="Georgia" >Georgia</option>
									<option value="HI" title="Hawaii" >Hawaii</option>

									<option value="ID" title="Idaho" >Idaho</option>
									<option value="IL" title="Illinois" >Illinois</option>
									<option value="IN" title="Indiana" >Indiana</option>
									<option value="IA" title="Iowa" >Iowa</option>
									<option value="KS" title="Kansas" >Kansas</option>
									<option value="KY" title="Kentucky" >Kentucky</option>

									<option value="LA" title="Louisiana" >Louisiana</option>
									<option value="ME" title="Maine" >Maine</option>
									<option value="MD" title="Maryland" >Maryland</option>
									<option value="MA" title="Massachusetts" >Massachusetts</option>
									<option value="MI" title="Michigan" >Michigan</option>
									<option value="MN" title="Minnesota" >Minnesota</option>

									<option value="MS" title="Mississippi" >Mississippi</option>
									<option value="MO" title="Missouri" >Missouri</option>
									<option value="MT" title="Montana" >Montana</option>
									<option value="NE" title="Nebraska" >Nebraska</option>
									<option value="NV" title="Nevada" >Nevada</option>
									<option value="NH" title="New Hampshire" >New Hampshire</option>

									<option value="NJ" title="New Jersey" >New Jersey</option>
									<option value="NM" title="New Mexico" >New Mexico</option>
									<option value="NY" title="New York" >New York</option>
									<option value="NC" title="North Carolina" >North Carolina</option>
									<option value="ND" title="North Dakota" >North Dakota</option>
									<option value="OH" title="Ohio" >Ohio</option>

									<option value="OK" title="Oklahoma" >Oklahoma</option>
									<option value="OR" title="Oregon" >Oregon</option>
									<option value="PA" title="Pennsylvania" >Pennsylvania</option>
									<option value="RI" title="Rhode Island" >Rhode Island</option>
									<option value="SC" title="South Carolina" >South Carolina</option>
									<option value="SD" title="South Dakota" >South Dakota</option>

									<option value="TN" title="Tennessee" >Tennessee</option>
									<option value="TX" title="Texas" >Texas</option>
									<option value="UT" title="Utah" >Utah</option>
									<option value="VT" title="Vermont" >Vermont</option>
									<option value="VA" title="Virginia" >Virginia</option>
									<option value="WA" title="Washington" >Washington</option>

									<option value="WV" title="West Virginia" >West Virginia</option>
									<option value="WI" title="Wisconsin" >Wisconsin</option>
									<option value="WY" title="Wyoming" >Wyoming</option>
								</select>
						</td>
					</tr>
					<tr>
						<td class="title">
							<label for='zip'>Zip:</label>
						</td>
						<td class="field">
							<input type="text" name='zip' id='zip' class='std-field'>
						</td>
					</tr>
					-->
				</tbody>
			</table>


		<div class="field">
			<INPUT type='image' name="submit" src="/images/contact/submit.gif" title="Submit" alt='submit' class="actionbtn">
			<INPUT type='image' src="/images/contact/reset.gif" title="reset" alt='reset' class='otherbtn'
			onclick='(document.getElementById("contact-form")).reset(); return false;'>
		</div>
	</form>
	<div style='display: [var notice-display];' class='error-group'>
		<p>To prevent spam, you may only sumbit an application once every 5 minutes. You will
			be able to submit another application at <em>
			[var notice-open-time];</em>.
		</p>
	</div>
	<div class="float-catch"></div>
</div>