{source}
<!-- Do not modify the NAME value of any of the INPUT fields the FORM action, or any of the hidden fields (eg. input type=hidden). These are all required for this form to function correctly. -->
<style type="text/css">
.myForm td, input, select, textarea, checkbox {
font-family: tahoma;
font-size: 12px;
}
.required {
color: red;
}
</style>
<form method="post" action="http://www.myemailmarketerclient.com/form.php?form=19" id="frmSS19" onsubmit="return CheckForm19(this);">
<table class="myForm" border="0" cellpadding="2">
<tbody>
<tr>
<td class="text"><span class="required">*</span> First Name:</td>
<td class="text"><input name="CustomFields[2]" id="CustomFields_2_19" size="30" type="text" /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Last Name:</td>
<td class="text"><input name="CustomFields[3]" id="CustomFields_3_19" size="30" type="text" /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Address:</td>
<td class="text"><input name="CustomFields[23]" id="CustomFields_23_19" size="30" type="text" /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Suburb:</td>
<td class="text"><input name="CustomFields[75]" id="CustomFields_75_19" size="30" type="text" /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Post Code:</td>
<td class="text"><input name="CustomFields[77]" id="CustomFields_77_19" size="10" type="text" /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> State:</td>
<td class="text"><input name="CustomFields[76]" id="CustomFields_76_19" size="10" type="text" /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Country:</td>
<td class="text"><select name="CustomFields[11]" id="CustomFields_11_19"><option>Please Select</option><option value="AFG">Afghanistan</option><option value="ALB">Albania</option><option value="DZA">Algeria</option><option value="ASM">American Samoa</option><option value="AND">Andorra</option><option value="AGO">Angola</option><option value="AIA">Anguilla</option><option value="ATG">Antigua and Barbuda</option><option value="ARG">Argentina</option><option value="ARM">Armenia</option><option value="ABW">Aruba</option><option value="AUS" selected="selected">Australia</option><option value="AUT">Austria</option><option value="AZE">Azerbaijan</option><option value="BHS">Bahamas</option><option value="BHR">Bahrain</option><option value="BGD">Bangladesh</option><option value="BRB">Barbados</option><option value="BLR">Belarus</option><option value="BEL">Belgium</option><option value="BLZ">Belize</option><option value="BEN">Benin</option><option value="BMU">Bermuda</option><option value="BTN">Bhutan</option><option value="BOL">Bolivia</option><option value="BIH">Bosnia and Herzegovina</option><option value="BWA">Botswana</option><option value="NUL">Timor-Leste</option><option value="BRA">Brazil</option><option value="BRN">Brunei Darussalam</option><option value="BGR">Bulgaria</option><option value="BFA">Burkina Faso</option><option value="BDI">Burundi</option><option value="KHM">Cambodia</option><option value="CMR">Cameroon</option><option value="CAN">Canada</option><option value="CPV">Cape Verde</option><option value="CYM">Cayman Islands</option><option value="CAF">Central African Republic</option><option value="TCD">Chad</option><option value="CHL">Chile</option><option value="CHN">China</option><option value="COL">Colombia</option><option value="COM">Comoros</option><option value="COG">Congo</option><option value="COD">Congo, the Democratic Republic of the</option><option value="COK">Cook Islands</option><option value="CRI">Costa Rica</option><option value="HRV">Croatia</option><option value="CUB">Cuba</option><option value="CYP">Cyprus</option><option value="CZE">Czech Republic</option><option value="DNK">Denmark</option><option value="DJI">Djibouti</option><option value="DMA">Dominica</option><option value="DOM">Dominican Republic</option><option value="ECU">Ecuador</option><option value="EGY">Egypt</option><option value="SLV">El Salvador</option><option value="GNQ">Equatorial Guinea</option><option value="ERI">Eritrea</option><option value="EST">Estonia</option><option value="ETH">Ethiopia</option><option value="FLK">Falkland Islands (Malvinas)</option><option value="FRO">Faroe Islands</option><option value="FJI">Fiji</option><option value="FIN">Finland</option><option value="FRA">France</option><option value="GUF">French Guiana</option><option value="PYF">French Polynesia</option><option value="GAB">Gabon</option><option value="GMB">Gambia</option><option value="GEO">Georgia</option><option value="DEU">Germany</option><option value="GHA">Ghana</option><option value="GIB">Gibraltar</option><option value="GRC">Greece</option><option value="GRL">Greenland</option><option value="GRD">Grenada</option><option value="GLP">Guadeloupe</option><option value="GUM">Guam</option><option value="GTM">Guatemala</option><option value="GIN">Guinea</option><option value="GNB">Guinea-Bissau</option><option value="GUY">Guyana</option><option value="HTI">Haiti</option><option value="VAT">Holy See (Vatican City State)</option><option value="HND">Honduras</option><option value="HKG">Hong Kong</option><option value="HUN">Hungary</option><option value="ISL">Iceland</option><option value="IND">India</option><option value="IDN">Indonesia</option><option value="IRN">Iran, Islamic Republic of</option><option value="IRQ">Iraq</option><option value="IRL">Ireland</option><option value="ISR">Israel</option><option value="ITA">Italy</option><option value="JAM">Jamaica</option><option value="JPN">Japan</option><option value="JOR">Jordan</option><option value="KAZ">Kazakhstan</option><option value="KEN">Kenya</option><option value="KIR">Kiribati</option><option value="KOR">Korea, Republic of</option><option value="KWT">Kuwait</option><option value="KGZ">Kyrgyzstan</option><option value="LVA">Latvia</option><option value="LBN">Lebanon</option><option value="LSO">Lesotho</option><option value="LBR">Liberia</option><option value="LBY">Libyan Arab Jamahiriya</option><option value="LIE">Liechtenstein</option><option value="LTU">Lithuania</option><option value="LUX">Luxembourg</option><option value="MAC">Macao</option><option value="MKD">Macedonia, the Former Yugoslav Republic of</option><option value="MDG">Madagascar</option><option value="MWI">Malawi</option><option value="MYS">Malaysia</option><option value="MDV">Maldives</option><option value="MLI">Mali</option><option value="MLT">Malta</option><option value="MHL">Marshall Islands</option><option value="MTQ">Martinique</option><option value="MRT">Mauritania</option><option value="MUS">Mauritius</option><option value="MEX">Mexico</option><option value="FSM">Micronesia, Federated States of</option><option value="MDA">Moldova, Republic of</option><option value="MCO">Monaco</option><option value="MNG">Mongolia</option><option value="MSR">Montserrat</option><option value="MAR">Morocco</option><option value="MOZ">Mozambique</option><option value="MMR">Myanmar</option><option value="NAM">Namibia</option><option value="NRU">Nauru</option><option value="NPL">Nepal</option><option value="NLD">Netherlands</option><option value="ANT">Netherlands Antilles</option><option value="NCL">New Caledonia</option><option value="NZL">New Zealand</option><option value="NIC">Nicaragua</option><option value="NER">Niger</option><option value="NGA">Nigeria</option><option value="NIU">Niue</option><option value="NFK">Norfolk Island</option><option value="MNP">Northern Mariana Islands</option><option value="NOR">Norway</option><option value="OMN">Oman</option><option value="PAK">Pakistan</option><option value="PLW">Palau</option><option value="PAN">Panama</option><option value="PNG">Papua New Guinea</option><option value="PRY">Paraguay</option><option value="PER">Peru</option><option value="PHL">Philippines</option><option value="PCN">Pitcairn</option><option value="POL">Poland</option><option value="PRT">Portugal</option><option value="PRI">Puerto Rico</option><option value="QAT">Qatar</option><option value="REU">Reunion</option><option value="ROM">Romania</option><option value="RUS">Russian Federation</option><option value="RWA">Rwanda</option><option value="SHN">Saint Helena</option><option value="KNA">Saint Kitts and Nevis</option><option value="LCA">Saint Lucia</option><option value="SPM">Saint Pierre and Miquelon</option><option value="VCT">Saint Vincent and the Grenadines</option><option value="WSM">Samoa</option><option value="SMR">San Marino</option><option value="STP">Sao Tome and Principe</option><option value="SAU">Saudi Arabia</option><option value="SEN">Senegal</option><option value="SRB">Serbia</option><option value="SYC">Seychelles</option><option value="SLE">Sierra Leone</option><option value="SGP">Singapore</option><option value="SVK">Slovakia</option><option value="SVN">Slovenia</option><option value="SLB">Solomon Islands</option><option value="SOM">Somalia</option><option value="ZAF">South Africa</option><option value="ESP">Spain</option><option value="LKA">Sri Lanka</option><option value="SDN">Sudan</option><option value="SUR">Suriname</option><option value="SJM">Svalbard and Jan Mayen</option><option value="SWZ">Swaziland</option><option value="SWE">Sweden</option><option value="CHE">Switzerland</option><option value="SYR">Syrian Arab Republic</option><option value="TWN">Taiwan, Province of China</option><option value="TJK">Tajikistan</option><option value="TZA">Tanzania, United Republic of</option><option value="THA">Thailand</option><option value="TGO">Togo</option><option value="TKL">Tokelau</option><option value="TON">Tonga</option><option value="TTO">Trinidad and Tobago</option><option value="TUN">Tunisia</option><option value="TUR">Turkey</option><option value="TKM">Turkmenistan</option><option value="TCA">Turks and Caicos Islands</option><option value="TUV">Tuvalu</option><option value="UGA">Uganda</option><option value="UKR">Ukraine</option><option value="ARE">United Arab Emirates</option><option value="GBR">United Kingdom</option><option value="USA">United States</option><option value="URY">Uruguay</option><option value="UZB">Uzbekistan</option><option value="VUT">Vanuatu</option><option value="VEN">Venezuela</option><option value="VNM">Viet Nam</option><option value="VGB">Virgin Islands, British</option><option value="VIR">Virgin Islands, U.s.</option><option value="WLF">Wallis and Futuna</option><option value="ESH">Western Sahara</option><option value="YEM">Yemen</option><option value="ZMB">Zambia</option><option value="ZWE">Zimbabwe</option> </select></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Contact No:</td>
<td class="text"><input name="CustomFields[93]" id="CustomFields_93_19" size="10" type="text" /></td>
</tr>
<tr>
<td class="text"> Product Interest:</td>
<td class="text"><label for="CustomFields[94_19]_Valve Saver Fluid"><input id="CustomFields[94_19]_Valve Saver Fluid" name="CustomFields[94][]" value="Valve Saver Fluid" type="checkbox" />Valve Saver Fluid</label><br /><label for="CustomFields[94_19]_Diesel Conditioner"><input id="CustomFields[94_19]_Diesel Conditioner" name="CustomFields[94][]" value="Diesel Conditioner" type="checkbox" />Diesel Conditioner</label><br /><label for="CustomFields[94_19]_Heavy Duty Oil Stabiliser"><input id="CustomFields[94_19]_Heavy Duty Oil Stabiliser" name="CustomFields[94][]" value="Heavy Duty Oil Stabiliser" type="checkbox" />Heavy Duty Oil Stabiliser</label><br /><label for="CustomFields[94_19]_Injector Cleaner"><input id="CustomFields[94_19]_Injector Cleaner" name="CustomFields[94][]" value="Injector Cleaner" type="checkbox" />Injector Cleaner</label><br /><label for="CustomFields[94_19]_Valve Saver Kit"><input id="CustomFields[94_19]_Valve Saver Kit" name="CustomFields[94][]" value="Valve Saver Kit" type="checkbox" />Valve Saver Kit</label><br /><label for="CustomFields[94_19]_Electronic Valve Saver Kit"><input id="CustomFields[94_19]_Electronic Valve Saver Kit" name="CustomFields[94][]" value="Electronic Valve Saver Kit" type="checkbox" />Electronic Valve Saver Kit</label><br /></td>
</tr>
<tr>
<td class="text"><span class="required">*</span> Your Email Address:</td>
<td class="text"><input name="email" size="30" type="text" /></td>
</tr>
<input name="format" value="h" type="hidden" />
<tr>
<td class="text"><span class="required">*</span> Enter the security code shown:</td>
<td class="text">
<script type="text/javascript">
if (!Application) var Application = {};
if (!Application.Page) Application.Page = {};
if (!Application.Page.ClientCAPTCHA) {
Application.Page.ClientCAPTCHA = {
sessionIDString: '',
captchaURL: [],
getRandomLetter: function () { return String.fromCharCode(Application.Page.ClientCAPTCHA.getRandom(65,90)); },
getRandom: function(lowerBound, upperBound) { return Math.floor((upperBound - lowerBound + 1) * Math.random() + lowerBound); },
getSID: function() {
if (Application.Page.ClientCAPTCHA.sessionIDString.length <= 0) {
var tempSessionIDString = '';
for (var i = 0; i < 32; ++i) tempSessionIDString += Application.Page.ClientCAPTCHA.getRandomLetter();
Application.Page.ClientCAPTCHA.sessionIDString.length = tempSessionIDString;
}
return Application.Page.ClientCAPTCHA.sessionIDString;
},
getURL: function() {
if (Application.Page.ClientCAPTCHA.captchaURL.length <= 0) {
var tempURL = 'http://www.myemailmarketerclient.com/admin/resources/form_designs/captcha/index.php?c=';
tempURL += Application.Page.ClientCAPTCHA.getRandom(1,1000);
tempURL += '&ss=' + Application.Page.ClientCAPTCHA.getSID();
Application.Page.ClientCAPTCHA.captchaURL.push(tempURL);
}
return Application.Page.ClientCAPTCHA.captchaURL;
}
}
}
var temp = Application.Page.ClientCAPTCHA.getURL();
for (var i = 0, j = temp.length; i < j; i++) document.write('<img src="' + temp[i] + '" alt="img' + i + '" />');
</script>
<br /><input name="captcha" type="text" /></td>
</tr>
<tr>
<td></td>
<td class="text"><input value="Subscribe" type="submit" /> <br /><br /></td>
</tr>
</tbody>
</table>
</form>
<script type="text/javascript">
function CheckMultiple19(frm, name) {
for (var i=0; i < frm.length; i++)
{
fldObj = frm.elements[i];
fldId = fldObj.id;
if (fldId) {
var fieldnamecheck=fldObj.id.indexOf(name);
if (fieldnamecheck != -1) {
if (fldObj.checked) {
return true;
}
}
}
}
return false;
}
function CheckForm19(f) {
var email_re = /[a-z0-9!#$%&'*+\/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&'*+\/=?^_`{|}~-]+)*@(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?/i;
if (!email_re.test(f.email.value)) {
alert("Please enter your email address.");
f.email.focus();
return false;
}
if (f.captcha.value == "") {
alert("Please enter the security code shown");
f.captcha.focus();
return false;
}
var fname = "CustomFields_2_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field First Name*");
fld.focus();
return false;
}
var fname = "CustomFields_3_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field Last Name*");
fld.focus();
return false;
}
var fname = "CustomFields_23_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field Address*");
fld.focus();
return false;
}
var fname = "CustomFields_75_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field Suburb*");
fld.focus();
return false;
}
var fname = "CustomFields_77_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field Post Code*");
fld.focus();
return false;
}
var fname = "CustomFields_76_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field State*");
fld.focus();
return false;
}
var fname = "CustomFields_11_19";
var fld = document.getElementById(fname);
if (fld.selectedIndex == -1 || fld.selectedIndex == 0) {
alert("Please choose an option for field Country*");
fld.focus();
return false;
}
var fname = "CustomFields_93_19";
var fld = document.getElementById(fname);
if (fld.value == "") {
alert("Please enter a value for field Contact No*");
fld.focus();
return false;
}
return true;
}
</script>
{/source}
