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<?php
require_once('includes/header.php');
?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>USA Grant Applications - Contact Us</title>
<?include('header.php');?>
<?include('nav.php');?>
<h1>Contact Us</h1>
<p><img src="/images/<?=$siteKey?>/image_myaccount.jpg" border="0" align="left" style="margin:0 5 20 0px" /> Having problems with site, or with a specific issue in the grant process? Simply choose what subject you want us to address and email your question via this form, and we'll respond as soon as we can. Not your correct contact information? Simply click the "<span class="edit_"><a href="#">edit</a></span>" link below and update your info.</p>
<br clear="all" />
<div style="font-family: Verdana;font-size: 10pt;font-weight: bold;color: #d147oc" align="center"><?if($msg)echo$msg;?></div>
<form name="theForm" id="theForm" action="<?=$PHP_SELF?>" method="post">
<table cellpadding="0" cellspacing="0" style="border:1px solid #EAEAEA" bgcolor="#e1e1e1" align="center" width="500">
<tr>
<td>
<table border="0" cellpadding="0" cellspacing="2" width="100%" style="margin-top:5px;margin-right:5px;margin-left:5px;margin-bottom:5px">
<tr>
<td align="left" width="150"><font style="font:bold 10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><b> First Name:</b></font></td>
<td align="left" width="346"><input type="text" name="fname" size="25" value=""></td>
</tr>
<tr>
<td align="left"><font style="font:bold 10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><b> Last Name:</b></font></td>
<td align="left"><input type="text" name="lname" size="25" value=""></td>
</tr>
<tr>
<td align="left"><font style="font:bold 10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><b>Phone Number:</b></font></td>
<td align="left"><input name="PHONE" size="25" type="text"></td>
</tr>
<tr>
<td align="left"><font style="font:bold 10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><b> Email address:</b></font></td>
<td colspan="3" align="left">
<script language="JavaScript">function echeck(str) {
var at="@"
var dot="."
var lat=str.indexOf(at)
var lstr=str.length
var ldot=str.indexOf(dot)
if (str.indexOf(at)==-1){
alert("This email address is incomplete.\n Please enter a valid email address.")
return false
}
if (str.indexOf(at)==-1 || str.indexOf(at)==0 || str.indexOf(at)==lstr){
alert("Invalid E-mail ID")
return false
}
if (str.indexOf(dot)==-1 || str.indexOf(dot)==0 || str.indexOf(dot)==lstr){
alert("Invalid E-mail ID")
return false
}
if (str.indexOf(at,(lat+1))!=-1){
alert("Invalid E-mail ID")
return false
}
if (str.substring(lat-1,lat)==dot || str.substring(lat+1,lat+2)==dot){
alert("Invalid E-mail ID")
return false
}
if (str.indexOf(dot,(lat+2))==-1){
alert("Invalid E-mail ID")
return false
}
if (str.indexOf(" ")!=-1){
alert("Invalid E-mail ID")
return false
}
return true
}
function ValidateForm(){
var emailID=document.theForm.EMAIL
if ((emailID.value==null)||(emailID.value=="")){
alert("Please Enter your Email ID")
emailID.focus()
return false
}
if (echeck(emailID.value)==false){
emailID.value=""
emailID.focus()
return false
}
return true
}
</script>
<input type="text" name="EMAIL" size="25" onChange="ValidateForm()"></td>
</tr>
<tr>
<td align="left"><font style="font:bold 10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><b> Reconfirm Email:</b></font></td>
<td colspan="3" align="left">
<input type="text" name="recon" size="25" onChange="ValidateForm()"></td>
</tr>
<tr>
<td align="left" colspan="2" style="padding:20px 0px 5px 0px"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><strong>Are you a VIP Grants member?</strong><br>
Yes <input type="radio" name="ordered" value="yes" style="margin-right:20px" onClick="document.all.questionairre.style.display = 'block'">No <input type="radio" name="ordered" value="no" onClick="document.all.questionairre.style.display = 'none'"></font>
</td>
</tr>
<tr>
<td colspan="2">
<table cellspacing="2" cellpadding="0" border="0" style="border:1px solid #173752;background:#43bbe3;width:435px;margin:0px 0px 5px 25px" class="none" id="questionairre">
<tr>
<td colspan="2" style="background:#eeeeee;font:bold 9pt/120% verdana,arial,helvetica,sans-serif;color:#173752;text-align:center;height:20px">PLEASE INCLUDE YOUR ORDER INFORMATION</td>
</tr>
<tr>
<td align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">Date You Registered:</font></td>
<td align="left">
<input type="text" name="recon" size="25" onChange="ValidateForm()"></td>
</tr>
<tr>
<td></td>
<td align="center" style="padding-bottom:5px"><font style="font:8pt/100% verdana;color:#ffffff">Format <em>(mm/dd/yyyy)</em></font></td>
</tr>
<tr>
<td align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">Payment Type:</font></td>
<td colspan="3" align="left">
<select name="paytype">
<option selected style="font:italics 9pt/100% verdana">--select--</option>
<option>Visa</option>
<option>Mastercard</option>
<option>AMEX</option>
<option>Discover</option>
<option>eCheck</option>
</select></td>
</tr>
<tr>
<td align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">Last 4 digits of cc/check:</font></td>
<td colspan="3" align="left">
<input type="text" name="4digit" maxlength="4" size="6" onChange="ValidateForm()"></td>
</tr>
<tr>
<td class="spacer"></td>
</tr>
<tr>
<td align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">Home Address:</font></td>
<td colspan="3" align="left">
<input type="text" name="shipadd" size="25" onChange="ValidateForm()"></td>
</tr>
<tr>
<td align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">State:</font></td>
<td colspan="3" align="left">
<select name="state">
<option value="" selected="selected">--select--</option>
<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 align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">City:</font></td>
<td colspan="3" align="left">
<input type="text" name="city" size="25" onChange="ValidateForm()"></td>
</tr>
<tr>
<td align="left"><font style="font:10pt/120% verdana,arial,helvetica,sans-serif;color:#ffffff">Zip:</font></td>
<td colspan="3" align="left">
<input type="text" name="zip" size="7" onChange="ValidateForm()"></td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left"><font style="font:bold 10pt/120% verdana,arial,helvetica,sans-serif;color:#173752"><b> Subject of Email:</b></font></td>
<td colspan="3"><input type="text" size="50" name="SUBJECT" style="width:300px"></td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="center" class="column" width="100%"><br><font size="2" color="#173752" face="Verdana, Arial, Helvetica, sans-serif"><b>Enter your question or comments here:</b><br>
<textarea cols="60" name="COMMENTS" rows="5" style="width:400px"></textarea></font><br><br>
</td>
</tr>
</table><br>
<table border="0" cellpadding="0" cellspacing="0" width="470" align="center">
<tr>
<td align="center" class="column"><input type="submit" onClick="document.theForm.submit();" value="" style="background: url(images/submit.jpg) no-repeat;border:0px;width:220px;height:58px;cursor:pointer;cursor:hand">
</td>
</tr>
</table></form>
</div>
<?include('footer.php');?>