function checkform(obj) {
	var checkboxcount;
	
		
			
			
					
					obj.fname.value=texttrim(obj.fname.value);
					if(obj.fname.value=="") {
						alert("Please enter your first name.");
						obj.fname.focus();
						return false;
					}
				
		
	
		
			
			
					
					obj.lname.value=texttrim(obj.lname.value);
					if(obj.lname.value=="") {
						alert("Please enter your last name.");
						obj.lname.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;
					}
				
		
	
		
	
		
	
		
			
			
					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;
					}
				
		
	
		
			
			
					
					obj.country.value=texttrim(obj.country.value);
					if(obj.country.value=="") {
						
								
								
									
								
								alert("Please enter your Country.");
							
						obj.country.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+"'>");






	leadsource="LPCT";



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='fname_required' value='You did not enter your [First Name]'>");
			
			document.write("First Name :</td><td>&nbsp;&nbsp;</td><td><input type='text' name='fname'></td></tr>");
		

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

	
		
	



document.write("<select name='country' style='width:110px;'>");
	document.write("<option value='USA'>USA</option>");
	
		document.write("<option value='Afghanistan'>Afghanistan</option>");
	
		document.write("<option value='Albania'>Albania</option>");
	
		document.write("<option value='Algeria'>Algeria</option>");
	
		document.write("<option value='Angola'>Angola</option>");
	
		document.write("<option value='Antarctica'>Antarctica</option>");
	
		document.write("<option value='Argentina'>Argentina</option>");
	
		document.write("<option value='Armenia'>Armenia</option>");
	
		document.write("<option value='Aruba'>Aruba</option>");
	
		document.write("<option value='Australia'>Australia</option>");
	
		document.write("<option value='Austria'>Austria</option>");
	
		document.write("<option value='Azerbaijan'>Azerbaijan</option>");
	
		document.write("<option value='Bahamas'>Bahamas</option>");
	
		document.write("<option value='Bahrain'>Bahrain</option>");
	
		document.write("<option value='Bangladesh'>Bangladesh</option>");
	
		document.write("<option value='Belarus'>Belarus</option>");
	
		document.write("<option value='Belgium'>Belgium</option>");
	
		document.write("<option value='Belize'>Belize</option>");
	
		document.write("<option value='Bermuda'>Bermuda</option>");
	
		document.write("<option value='Bolivia'>Bolivia</option>");
	
		document.write("<option value='Bosnia Herzogovina'>Bosnia Herzogovina</option>");
	
		document.write("<option value='Botswana'>Botswana</option>");
	
		document.write("<option value='Brazil'>Brazil</option>");
	
		document.write("<option value='Bulgaria'>Bulgaria</option>");
	
		document.write("<option value='Burundi'>Burundi</option>");
	
		document.write("<option value='Cambodia'>Cambodia</option>");
	
		document.write("<option value='Cameroon'>Cameroon</option>");
	
		document.write("<option value='Canada'>Canada</option>");
	
		document.write("<option value='Cayman Islands'>Cayman Islands</option>");
	
		document.write("<option value='Central African Rep.'>Central African Rep.</option>");
	
		document.write("<option value='Chad'>Chad</option>");
	
		document.write("<option value='Chile'>Chile</option>");
	
		document.write("<option value='China'>China</option>");
	
		document.write("<option value='Colombia'>Colombia</option>");
	
		document.write("<option value='Congo'>Congo</option>");
	
		document.write("<option value='Costa Rica'>Costa Rica</option>");
	
		document.write("<option value='Croatia'>Croatia</option>");
	
		document.write("<option value='Cuba'>Cuba</option>");
	
		document.write("<option value='Cyprus'>Cyprus</option>");
	
		document.write("<option value='Czech Republic'>Czech Republic</option>");
	
		document.write("<option value='Denmark'>Denmark</option>");
	
		document.write("<option value='Dominica'>Dominica</option>");
	
		document.write("<option value='Dominican Republic'>Dominican Republic</option>");
	
		document.write("<option value='Ecuador'>Ecuador</option>");
	
		document.write("<option value='Egypt'>Egypt</option>");
	
		document.write("<option value='El Salvador'>El Salvador</option>");
	
		document.write("<option value='Estonia'>Estonia</option>");
	
		document.write("<option value='Ethiopia'>Ethiopia</option>");
	
		document.write("<option value='Finland'>Finland</option>");
	
		document.write("<option value='France'>France</option>");
	
		document.write("<option value='Gabon'>Gabon</option>");
	
		document.write("<option value='Gambia'>Gambia</option>");
	
		document.write("<option value='Georgia'>Georgia</option>");
	
		document.write("<option value='Germany'>Germany</option>");
	
		document.write("<option value='Ghana'>Ghana</option>");
	
		document.write("<option value='Gibraltar'>Gibraltar</option>");
	
		document.write("<option value='Greece'>Greece</option>");
	
		document.write("<option value='Greenland'>Greenland</option>");
	
		document.write("<option value='Guatemala'>Guatemala</option>");
	
		document.write("<option value='Haiti'>Haiti</option>");
	
		document.write("<option value='Honduras'>Honduras</option>");
	
		document.write("<option value='Hong Kong'>Hong Kong</option>");
	
		document.write("<option value='Hungary'>Hungary</option>");
	
		document.write("<option value='Iceland'>Iceland</option>");
	
		document.write("<option value='India'>India</option>");
	
		document.write("<option value='Indonesia'>Indonesia</option>");
	
		document.write("<option value='Iran'>Iran</option>");
	
		document.write("<option value='Iraq'>Iraq</option>");
	
		document.write("<option value='Ireland'>Ireland</option>");
	
		document.write("<option value='Israel'>Israel</option>");
	
		document.write("<option value='Italy'>Italy</option>");
	
		document.write("<option value='Jamaica'>Jamaica</option>");
	
		document.write("<option value='Japan'>Japan</option>");
	
		document.write("<option value='Jordan'>Jordan</option>");
	
		document.write("<option value='Kazakhstan'>Kazakhstan</option>");
	
		document.write("<option value='Kenya'>Kenya</option>");
	
		document.write("<option value='Korea, North'>Korea, North</option>");
	
		document.write("<option value='Korea, South'>Korea, South</option>");
	
		document.write("<option value='Latvia'>Latvia</option>");
	
		document.write("<option value='Lebanon'>Lebanon</option>");
	
		document.write("<option value='Liberia'>Liberia</option>");
	
		document.write("<option value='Libya'>Libya</option>");
	
		document.write("<option value='Liechtenstein'>Liechtenstein</option>");
	
		document.write("<option value='Lithuania'>Lithuania</option>");
	
		document.write("<option value='Luxembourg'>Luxembourg</option>");
	
		document.write("<option value='Macau'>Macau</option>");
	
		document.write("<option value='Macedonia'>Macedonia</option>");
	
		document.write("<option value='Madagascar'>Madagascar</option>");
	
		document.write("<option value='Malaysia'>Malaysia</option>");
	
		document.write("<option value='Malta'>Malta</option>");
	
		document.write("<option value='Mexico'>Mexico</option>");
	
		document.write("<option value='Micronesia'>Micronesia</option>");
	
		document.write("<option value='Moldova'>Moldova</option>");
	
		document.write("<option value='Monaco'>Monaco</option>");
	
		document.write("<option value='Mongolia'>Mongolia</option>");
	
		document.write("<option value='Montserrat'>Montserrat</option>");
	
		document.write("<option value='Morocco'>Morocco</option>");
	
		document.write("<option value='Mozambique'>Mozambique</option>");
	
		document.write("<option value='Nepal'>Nepal</option>");
	
		document.write("<option value='Netherlands'>Netherlands</option>");
	
		document.write("<option value='New Caledonia'>New Caledonia</option>");
	
		document.write("<option value='New Zealand'>New Zealand</option>");
	
		document.write("<option value='Nicaragua'>Nicaragua</option>");
	
		document.write("<option value='Niger'>Niger</option>");
	
		document.write("<option value='Nigeria'>Nigeria</option>");
	
		document.write("<option value='Norway'>Norway</option>");
	
		document.write("<option value='Oman'>Oman</option>");
	
		document.write("<option value='Pakistan'>Pakistan</option>");
	
		document.write("<option value='Palau'>Palau</option>");
	
		document.write("<option value='Panama'>Panama</option>");
	
		document.write("<option value='Papua New Guinea'>Papua New Guinea</option>");
	
		document.write("<option value='Paraguay'>Paraguay</option>");
	
		document.write("<option value='Peru'>Peru</option>");
	
		document.write("<option value='Philippines'>Philippines</option>");
	
		document.write("<option value='Poland'>Poland</option>");
	
		document.write("<option value='Portugal'>Portugal</option>");
	
		document.write("<option value='Qatar'>Qatar</option>");
	
		document.write("<option value='Romania'>Romania</option>");
	
		document.write("<option value='Russian Federation'>Russian Federation</option>");
	
		document.write("<option value='Rwanda'>Rwanda</option>");
	
		document.write("<option value='Samoa'>Samoa</option>");
	
		document.write("<option value='Saudi Arabia'>Saudi Arabia</option>");
	
		document.write("<option value='Senegal'>Senegal</option>");
	
		document.write("<option value='Sierra Leone'>Sierra Leone</option>");
	
		document.write("<option value='Singapore'>Singapore</option>");
	
		document.write("<option value='Slovakia'>Slovakia</option>");
	
		document.write("<option value='Slovenia'>Slovenia</option>");
	
		document.write("<option value='Somalia'>Somalia</option>");
	
		document.write("<option value='South Africa'>South Africa</option>");
	
		document.write("<option value='Spain'>Spain</option>");
	
		document.write("<option value='Sri Lanka'>Sri Lanka</option>");
	
		document.write("<option value='Sudan'>Sudan</option>");
	
		document.write("<option value='Swaziland'>Swaziland</option>");
	
		document.write("<option value='Sweden'>Sweden</option>");
	
		document.write("<option value='Switzerland'>Switzerland</option>");
	
		document.write("<option value='Syria'>Syria</option>");
	
		document.write("<option value='Taiwan'>Taiwan</option>");
	
		document.write("<option value='Tajikistan'>Tajikistan</option>");
	
		document.write("<option value='Tanzania'>Tanzania</option>");
	
		document.write("<option value='Thailand'>Thailand</option>");
	
		document.write("<option value='Trinidad & Tobago'>Trinidad & Tobago</option>");
	
		document.write("<option value='Tunisia'>Tunisia</option>");
	
		document.write("<option value='Turkey'>Turkey</option>");
	
		document.write("<option value='Turkmenistan'>Turkmenistan</option>");
	
		document.write("<option value='Uganda'>Uganda</option>");
	
		document.write("<option value='Ukraine'>Ukraine</option>");
	
		document.write("<option value='United Arab Emirates'>United Arab Emirates</option>");
	
		document.write("<option value='United Kingdom'>United Kingdom</option>");
	
		document.write("<option value='Uruguay'>Uruguay</option>");
	
		document.write("<option value='USA'>USA</option>");
	
		document.write("<option value='Uzbekistan'>Uzbekistan</option>");
	
		document.write("<option value='Venezuela'>Venezuela</option>");
	
		document.write("<option value='Viet Nam'>Viet Nam</option>");
	
		document.write("<option value='Virgin Islands (Br.)'>Virgin Islands (Br.)</option>");
	
		document.write("<option value='Western Sahara'>Western Sahara</option>");
	
		document.write("<option value='Yemen'>Yemen</option>");
	
		document.write("<option value='Yugoslavia'>Yugoslavia</option>");
	
		document.write("<option value='Zaire'>Zaire</option>");
	
		document.write("<option value='Zambia'>Zambia</option>");
	
		document.write("<option value='Zimbabwe'>Zimbabwe</option>");
	
document.write("</select>");

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

	
		
	
	



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>");