function checkform(obj) {
	var checkboxcount;
	
		
			
			
					
					obj.name.value=texttrim(obj.name.value);
					if(obj.name.value=="") {
						alert("Please enter your full name.");
						obj.name.focus();
						return false;
					}
				
		
	
		
			
			
					
					obj.email.value=texttrim(obj.email.value);
					if(obj.email.value=="") {
						alert("Please enter your email address.");
						obj.email.focus();
						return false;
					}
					if(obj.email.value.indexOf("@")==-1) {
						alert("Email address must be valid and correct.");
						obj.email.focus();
						return false;
					}
					if(obj.email.value.indexOf(".",obj.email.value.indexOf("@"))==-1) {
						alert("Email address must be valid and correct.");
						obj.email.focus();
						return false;
					}
				
		
	
		
	
		
			
			
					
					obj.daytime_phone.value=texttrim(obj.daytime_phone.value);
					if(obj.daytime_phone.value=="") {
						alert("Please enter your telephone number.");
						obj.daytime_phone.focus();
						return false;
					}
				
		
	
		
	
		
	
		
			
			
					
					obj.city.value=texttrim(obj.city.value);
					if(obj.city.value=="") {
						alert("Please enter your city.");
						obj.city.focus();
						return false;
					}
				
		
	
		
			
			
					if(obj.state.selectedIndex==0) {
						alert("Please select your state.");
						obj.state.focus();
						return false;
					}
				
		
	
		
			
			
					
					obj.zip.value=texttrim(obj.zip.value);
					if(obj.zip.value=="") {
						alert("Please enter your zip code.");
						obj.zip.focus();
						return false;
					}
				
		
	
		
			
			
					if((obj.bus_or_pers[0].checked==false) && (obj.bus_or_pers[1].checked==false)) {
						alert("Please select business use or personal use.");
						obj.bus_or_pers[0].focus();
						return false;
					}
				
		
	
	return true;
}

function texttrim(invar) {
	while(invar.substr(0,1)==" ") { invar=invar.substring(1,invar.length); }
	while(invar.substr(invar.length-1,1)==" ") { invar=invar.substring(0,invar.length-1); }
	return invar;
}




	



document.write("<table cellpadding='0' cellspacing='0' border='0'>");
document.write("<form action='http://ssileadman.com/form2mail.cfm' method='post' onsubmit='return checkform(this)'>");
document.write("<input type='hidden' name='referer' value='"+self.location.href+"'>");






	function Get_Cookie(name) {
		
			var start = document.cookie.indexOf(name.toUpperCase() + '=');
		
		var len = start + name.length + 1;
		if ((!start) && (name != document.cookie.substring(0,name.length))) return null;
		if (start == -1) return null;
		var end = document.cookie.indexOf(';',len);
		if (end == -1) end = document.cookie.length;
		return unescape(document.cookie.substring(len,end));
	}
	var leadsource=Get_Cookie("leadsource");
	if(self.location.href.indexOf("?")!=-1) {
		var qs=self.location.href.substring(self.location.href.indexOf("?")+1,self.location.href.length);
		while(qs.indexOf("?")!=-1) {
			qs=qs.replace("?","&");
		}
		while(qs.indexOf(",")!=-1) {
			qs=qs.replace(",","&");
		}
		while(qs.indexOf(" ")!=-1) {
			qs=qs.replace(" ","");
		}
		var qs_array=qs.split("&");
		for(i=0;i<qs_array.length;i++) {
			if(qs_array[i].substr(0,7)=="source=") {
				if(qs_array[i].length>7) {
					leadsource=qs_array[i].substr(7,qs_array[i].length-7);
				}
			}
		}
	}



if(leadsource!=null){
	if(leadsource!="") {
		
			document.write("<input type='hidden' name='source' value='"+leadsource+"'>");
		
	}
}

	
		
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font><input type='hidden' name='name_required' value='You did not enter your [Name]'>");
			
			document.write("Name :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='name'></td></tr>");
		

	
		
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font><input type='hidden' name='email_required' value='You did not enter your [Email]'>");
			
			document.write("Email :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='email'></td></tr>");
		

	
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
			document.write("Company :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='company'></td></tr>");
		

	
		
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font><input type='hidden' name='daytime_phone_required' value='You did not enter your [Phone]'>");
			
			document.write("Phone :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='daytime_phone'></td></tr>");
		

	
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
			document.write("Phone :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='evening_phone'></td></tr>");
		

	
		
	
	
			document.write("<tr><td align='right' nowrap>Address :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='address1'></td></tr><tr><td>&nbsp;</td><td>&nbsp;&nbsp;</td><td><input type='text' name='address2'></td></tr>");
		

	
		
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font><input type='hidden' name='city_required' value='You did not enter your [City]'>");
			
			document.write("City :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='city'></td></tr>");
		

	
		
		
	
	
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font>");
			
			document.write("State :</td><td>&nbsp;&nbsp;</td><td>");
			
	
		
	




document.write("<select name='state'>");
	document.write("<option value=''>Your State</option>");
	
		document.write("<option value='AK'>Alaska</option>");
	
		document.write("<option value='AL'>Alabama</option>");
	
		document.write("<option value='AR'>Arkansas</option>");
	
		document.write("<option value='AZ'>Arizona</option>");
	
		document.write("<option value='CA'>California</option>");
	
		document.write("<option value='CO'>Colorado</option>");
	
		document.write("<option value='CT'>Connecticut</option>");
	
		document.write("<option value='DC'>District of Col.</option>");
	
		document.write("<option value='DE'>Delaware</option>");
	
		document.write("<option value='FL'>Florida</option>");
	
		document.write("<option value='GA'>Georgia</option>");
	
		document.write("<option value='HI'>Hawaii</option>");
	
		document.write("<option value='IA'>Iowa</option>");
	
		document.write("<option value='ID'>Idaho</option>");
	
		document.write("<option value='IL'>Illinois</option>");
	
		document.write("<option value='IN'>Indiana</option>");
	
		document.write("<option value='KS'>Kansas</option>");
	
		document.write("<option value='KY'>Kentucky</option>");
	
		document.write("<option value='LA'>Louisiana</option>");
	
		document.write("<option value='MA'>Massachusetts</option>");
	
		document.write("<option value='MD'>Maryland</option>");
	
		document.write("<option value='ME'>Maine</option>");
	
		document.write("<option value='MI'>Michigan</option>");
	
		document.write("<option value='MN'>Minnesota</option>");
	
		document.write("<option value='MO'>Missouri</option>");
	
		document.write("<option value='MS'>Mississippi</option>");
	
		document.write("<option value='MT'>Montana</option>");
	
		document.write("<option value='NC'>North Carolina</option>");
	
		document.write("<option value='ND'>North Dakota</option>");
	
		document.write("<option value='NE'>Nebraska</option>");
	
		document.write("<option value='NH'>New Hampshire</option>");
	
		document.write("<option value='NJ'>New Jersey</option>");
	
		document.write("<option value='NM'>New Mexico</option>");
	
		document.write("<option value='NV'>Nevada</option>");
	
		document.write("<option value='NY'>New York</option>");
	
		document.write("<option value='OH'>Ohio</option>");
	
		document.write("<option value='OK'>Oklahoma</option>");
	
		document.write("<option value='OR'>Oregon</option>");
	
		document.write("<option value='PA'>Pennsylvania</option>");
	
		document.write("<option value='RI'>Rhode Island</option>");
	
		document.write("<option value='SC'>South Carolina</option>");
	
		document.write("<option value='SD'>South Dakota</option>");
	
		document.write("<option value='TN'>Tennessee</option>");
	
		document.write("<option value='TX'>Texas</option>");
	
		document.write("<option value='UT'>Utah</option>");
	
		document.write("<option value='VA'>Virginia</option>");
	
		document.write("<option value='VT'>Vermont</option>");
	
		document.write("<option value='WA'>Washington</option>");
	
		document.write("<option value='WI'>Wisconsin</option>");
	
		document.write("<option value='WV'>West Virginia</option>");
	
		document.write("<option value='WY'>Wyoming</option>");
	
	document.write("<option value='Not Listed'>Not Listed</option>");
document.write("</select>");

			document.write("</td></tr>");
		

	
		
		
	
	
			
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font><input type='hidden' name='zip_required' value='You did not enter your [Zip Code]'>");
			
			document.write("Zip Code :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='zip'></td></tr>");
		

	
		
		
	
	
			document.write("<tr><td align='right' nowrap>");
			
				document.write("<font color='Red'>* </font>");
			
			document.write("Industry :</td><td>&nbsp;&nbsp;</td><td><select name='industry'><option>Individual (Single-user)<option>Education<option>Government<option>Corporate (Multi-user)<option>Reseller</select></td><td>");
			document.write("</td></tr>");
		


	document.write("<input type='hidden' name='country' value='USA'>");


document.write("<tr><td></td><td colspan='2' nowrap><input type='submit' value='Submit'></td></tr>");
document.write("<tr><td colspan='3' style='padding:0px;'><font size='-2'>QuickCert/Specialized Solutions values your<br>privacy. The information you send us is for<br>internal use only. It will not be sold, leased,<br>or passed on to anyone or any company<br>outside of QuickCert/SSI without your<br>express written consent.</font></td></tr>");
document.write("</form></table>");