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<!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.org - Business Application</title>
<script type="text/javascript">
// Create an associative array of 'pretty name' values
var prettynames = {
cc_fname:"First Name",
cc_lname:"Last Name",
cc_addr:"Address",
cc_city:"City",
cc_state:"State",
cc_zip:"Zip",
cc_phonearea:"Phone Number Area Code",
cc_phoneprefix:"Phone Number Prefix",
cc_phoneextension:"Phone Number Ending",
cc_email:"Email Address",
app_occupation:"Your occupation",
app_age:"Your age",
app_yearly_income:"Your yearly income",
app_funding_type:"The type of funding you are looking for",
app_amount_needed:"The amount of money you are going to need"
};
// Utility function that returns true if a string contains only
// whitespace characters
// Taken from "Javascript: The Definitive Guide" pg. 264
function isblank(s)
{
for (var i=0; i < s.length; i++)
{
var c = s.charAt(i);
if ((c!=' ') && (c != '\n') && (c != ''))
{
return false;
}
}
return true;
}
// Credit Card Validation Javascript
// copyright 12th May 2003, by Stephen Chapman, Felgall Pty Ltd
// You have permission to copy and use this javascript provided that
// the content of the script is not changed in any way.
function validateCreditCard(s) {
// remove non-numerics
var v = "0123456789";
var w = "";
for (i=0; i < s.length; i++) {
x = s.charAt(i);
if (v.indexOf(x,0) != -1)
w += x;
}
// validate number
j = w.length / 2;
if (j < 6.5 || j > 8 || j == 7) return false;
k = Math.floor(j);
m = Math.ceil(j) - k;
c = 0;
for (i=0; i<k; i++) {
a = w.charAt(i*2+m) * 2;
c += a > 9 ? Math.floor(a/10 + a%10) : a;
}
for (i=0; i<k+m; i++) c += w.charAt(i*2+1-m) * 1;
return (c%10 == 0);
}
function verify(f)
{
// Taken from "Javascript: The Definitive Guide" pg. 264.
// Modified heavily to suit our needs
// Loop through each element of the form and validate each item
//
// Set the parameters for each field to be valid
// If a field doesn't have any modifiers it is assumed to be
// a text field that can not be blank.
f.cc_phonearea.requiredlength = 3;
f.cc_phonearea.numeric = true;
f.cc_phoneprefix.requiredlength = 3;
f.cc_phoneprefix.numeric = true;
f.cc_phoneextension.requiredlength = 4;
f.cc_phoneextension.numeric = true;
f.cc_zip.requiredlength = 5;
f.cc_zip.numeric = true;
var msg;
var empty_fields = "";
var errors = "";
for (var i=0; i < f.length; i++)
{
var element = f.elements[i];
//document.getElementById('errorconsole').innerHTML += element.name + ":" + element.type + "<br>";
if (element.type == 'text')
{
if ( (element.value == null || element.value == "") || isblank(element.value) )
{
empty_fields += "\n " + prettynames[element.name];
continue;
}
if (element.numeric)
{
var v = parseFloat(element.value);
if (isNaN(v))
{
errors +="- The field " + prettynames[element.name] + " must be a number\n";
}
}
if ( (element.requiredlength > 0) && (element.value.length != element.requiredlength) )
{
errors += "- The field " + prettynames[element.name] + " must be " + element.requiredlength + " digits long\n";
}
}
else if (element.type == 'select-one')
{
// The first option, option[0] can not be selected
if ( (element.value == null || element.value == "" || element.selectedIndex == 0) || isblank(element.value) )
{
empty_fields += "\n " + prettynames[element.name];
continue;
}
}
}
if (!empty_fields && !errors) { return true; }
msg = "__________________________________\n\n";
msg += "The form was not submitted because of the following error(s).\n";
msg += "Please correct these error(s) and re-submit.\n";
msg += "__________________________________\n\n";
if (empty_fields)
{
msg += "- The following required field(s) are empty:" + empty_fields + "\n";
if (errors) { msg += "\n"; }
}
msg += errors;
alert(msg);
return false;
}
</script>
<? include('header.php'); ?>
<tr>
<td style="width:100px;background-color:#dbd7d6;text-align:center" valign="top"></td>
<td style="width:590px;background-color:#ffffff;text-align:left;font:9pt/120% verdana;padding:10px 0px 0px 10px">
<form action="https://www.usagrantapplications.org/order.php" method="POST" name="application" onsubmit="return verify(this);">
<img src="images/app_1.jpg" style="margin:5px 0px" border="0" />
<table cellpadding="3" cellspacing="0" class="questions red">
<tr>
<td class="q" width="30%">First Name:</td>
<td class="a" colspan="3"><input type="text" name="cc_fname" size="40"></td>
</tr>
<tr>
<td class="q" width="30%">Last Name:</td>
<td class="a" colspan="3"><input type="text" name="cc_lname" size="40"></td>
</tr>
<tr>
<td class="q" width="30%">Street Address:</td>
<td class="a" colspan="3"><input type="text" name="cc_addr" size="40"></td>
</tr>
<tr>
<td class="q" width="30%">City:</td>
<td class="a" colspan="3"><input type="text" name="cc_city" size="40"></td>
</tr>
<tr>
<td class="q" width="30%">State:</td>
<td class="a" colspan="3">
<select name="cc_state">
<option selected>Please Select Your State</option>
<option value="AK">Alaska</option>
<option value="AL">Alabama</option>
<option value="AR">Arkansas</option>
<option value="AZ">Arizona</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DC">District of Columbia</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="IA">Iowa</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="MA">Massachusetts</option>
<option value="MD">Maryland</option>
<option value="ME">Maine</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MO">Missouri</option>
<option value="MS">Mississippi</option>
<option value="MT">Montana</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="NE">Nebraska</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NV">Nevada</option>
<option value="NY">New York</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</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="VA">Virginia</option>
<option value="VT">Vermont</option>
<option value="WA">Washington</option>
<option value="WI">Wisconsin</option>
<option value="WV">West Virginia</option>
<option value="WY">Wyoming</option>
</select>
</td>
</tr>
<tr>
<td class="q" width="30%">Zip:</td>
<td class="a"><input type="text" name="cc_zip" size="10"></td>
</tr>
<tr>
<td class="q" width="30%">Day Phone:</td>
<td class="a"><input type="text" name="cc_phonearea" size="3">-<input type="text" name="cc_phoneprefix" size="3">-<input type="text" name="cc_phoneextension" size="5"></td>
</tr>
<tr>
<td class="q" width="30%">Alternate Phone:</td>
<td class="a"><input type="text" name="cc_phonearea2" size="3">-<input type="text" name="cc_phoneprefix2" size="3">-<input type="text" name="cc_phoneextension2" size="5"></td>
</tr>
<tr>
<td class="q" width="30%">Email:</td>
<td class="a" colspan="3"><input type="text" name="cc_email" size="40"></td>
</tr>
</table>
<table cellpadding="3" cellspacing="0" class="questions red">
<tr>
<td class="q" width="60%">What is your occupation?</td>
<td class="a"><input type="text" name="app_occupation" size="30"></td>
</tr>
<tr>
<td class="q" width="60%">What is your age?</td>
<td class="a"><select name="app_age">
<option selected>Please Choose Range</option>
<option value="18-25">18-25</option>
<option value="26-34">26-34</option>
<option value="35-49">35-49</option>
<option value="50-65">50-65</option>
<option value="66-80">66-80</option>
<option value="80+">80 +</option>
</select></td>
</tr>
<tr>
<td class="q" width="60%">What is your yearly income?</td>
<td class="a"><select size="1" name="app_yearly_income">
<option selected>Please Choose One</option>
<option value="Less than $15,000">Less than $15,000</option>
<option value="$15,000 - $25,000">$15,000 - $25,000</option>
<option value="$25,000 - $50,000">$25,000 - $50,000</option>
<option value="$50,000 - $100,000">$50,000 - $100,000</option>
<option value="$100,000 or More">$100,000 or More</option>
</select></td>
</tr>
<tr>
<td class="q" width="60%">What type of funding are you looking for?</td>
<td class="a">
<select size="1" name="app_funding_type">
<option selected>Please Choose One</option>
<option value="Government Procurement Programs">Government Procurement Programs</option>
<option value="Import And Export">Import And Export</option>
<option value="Non-Profit Organizations">Non-Profit Organizations</option>
<option value="Research and Development">Research and Development</option>
<option value="Business Planning Assistance">Business Planning Assistance</option>
<option value="Product Development">Product Development</option>
<option value="Employee Assistance Funding">Employee Assistance Funding</option>
<option value="Business Start-Up Capital">Business Start-Up Capital</option>
<option value="Business Expansion funding">Business Expansion funding</option>
<option value="Home Business Assistance">Home Business Assistance</option>
<option value="Free Small Business Management Assistance">Free Small Business Management Assistance</option>
<option value="Women's Business Ownership Assistance">Women's Business Ownership Assistance</option>
<option value="Small Business Loans">Small Business Loans</option>
<option value="R&D Funding Programs">R&D Funding Programs</option>
<option value="Other">Other</option>
<option value="Small Business Ventures">Small Business Ventures</option>
</select>
</td>
</tr>
<tr>
<td class="q" width="60%">How much money are you going to need?</td>
<td class="a"><select size="1" name="app_amount_needed">
<option selected>Please Choose One</option>
<option value="$500-$10,000">$500 - $10,000</option>
<option value="$10,000 - $25,000">$10,000 - $25,000</option>
<option value="$25,000 - $50,000">$25,000 - $50,000</option>
<option value="$50,000 - $100,000">$50,000 - $100,000</option>
<option value="$100,000 or More">$100,000 or More</option>
</select>
</td>
</tr>
</table>
<center><input type="submit" value="" style="background:url(images/submit.jpg) top center no-repeat;width:144px;height:63px;border:0px;margin:20px auto;cursor:pointer"></center>
<input type="hidden" name="application" value="application">
</form>
</td>
</tr>
<? include('footer.php'); ?>