<!-- Page Content Divider -->
<div id=\"ErrRequired\" style=\"display: none;\" class=\"form_submit_error_txt\">
    A required field has not been filled in. Please try again.
</div>
<div id=\"ErrEmail\" style=\"display: none;\" class=\"form_submit_error_txt\">
    Your email is blank or doesn&#39;t match the confirm. Please try again.
</div>
<div id=\"ErrDuplicate\" style=\"display: none;\" class=\"form_submit_error_txt\">
    The email address you entered already exists in our system. Please try again.
</div>
<div id=\"ErrBadEmail\" style=\"display: none;\" class=\"form_submit_error_txt\">
    The email address you entered is not a valid email address. Please try again.
</div>
<div id=\"ErrCaptcha\" style=\"display: none;\" class=\"form_submit_error_txt\">
    The Captcha you entered does not match. Please try again.
</div>
<div id=\"ErrFileSize\" style=\"display: none;\" class=\"form_submit_error_txt\">
    The file you are trying to send is too large for email.  Please select a different file.
</div>
<div id=\"ErrFileType\" style=\"display: none;\" class=\"form_submit_error_txt\">
    The file you are trying to send is of a type that is not allowed to be be emailed.  Please select a different file.
</div>
<div id=\"ErrUpload\" style=\"display: none;\" class=\"form_submit_error_txt\">
    There was an error uploading your file.  Please try again.
</div>
<div id=\"ErrPhone\" style=\"display: none;\" class=\"form_submit_error_txt\">
    The phone number you entered is not a valid phone number.  Please re-enter your phone number.
</div>
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<p>&nbsp;</p>

			<h3>Enter Your Information Below:</h3>

			<p>&nbsp;</p>

			<div class=\"contact_form_wrapper\">
              
<form name=\"frmMailForm\" id=\"frmMailForm\" method=\"post\" action=\"/php/formmail.php\" enctype=\"multipart/form-data\">
  <div class=\"mail_form_div\">
    <table class=\"mail_form_table\">
        <tbody>

            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Name (First, Last):</span></td>
              <td class=\"mail_form_td\"><input type=\"text\" name=\"first_name\" id=\"first_name\" />
                <span class=\"mail_form_large_text\" style=\"color:#F00;\"><b>*</b></span>
                <input type=\"text\" name=\"last_name\" id=\"last_name\" /> </td>
            </tr>
			<tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Address:
              </span></td>
                <td class=\"mail_form_td\"><input name=\"address\" type=\"text\" id=\"address\" size=\"50\" /></td>

            </tr>
			<tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">&nbsp;
              </span></td>
                <td class=\"mail_form_td\"><input name=\"address2\" type=\"text\" id=\"address2\" size=\"50\" /></td>

            </tr>
			<tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">City, State ZIP:
                </span></td>
              <td class=\"mail_form_td\"><input name=\"city\" type=\"text\" id=\"city\" />
                , <select name=\"state\" id=\"state\" size=\"1\">
		<option >-not selected-</option>
		<option value=\"Alabama\" >Alabama</option>
		<option value=\"Alaska\" >Alaska</option>
		<option value=\"Arizona\" >Arizona</option>
		<option value=\"Arkansas\" >Arkansas</option>
		<option value=\"California\" >California</option>
		<option value=\"Colorado\" >Colorado</option>
		<option value=\"Connecticut\" >Connecticut</option>
		<option value=\"Delaware\" >Delaware</option>
		<option value=\"Dist of Columbia\" >Dist of Columbia</option>
		<option value=\"Florida\" >Florida</option>
		<option value=\"Georgia\" >Georgia</option>
		<option value=\"Hawaii\" >Hawaii</option>
		<option value=\"Idaho\" >Idaho</option>
		<option value=\"Illinois\" >Illinois</option>
		<option value=\"Indiana\" >Indiana</option>
		<option value=\"Iowa\" >Iowa</option>
		<option value=\"Kansas\" >Kansas</option>
		<option value=\"Kentucky\" >Kentucky</option>
		<option value=\"Louisiana\" >Louisiana</option>
		<option value=\"Maine\" >Maine</option>
		<option value=\"Maryland\" >Maryland</option>
		<option value=\"Massachusetts\" >Massachusetts</option>
		<option value=\"Michigan\" >Michigan</option>
		<option value=\"Minnesota\" >Minnesota</option>
		<option value=\"Mississippi\" >Mississippi</option>
		<option value=\"Missouri\" >Missouri</option>
		<option value=\"Montana\" >Montana</option>
		<option value=\"Nebraska\" >Nebraska</option>
		<option value=\"Nevada\" >Nevada</option>
		<option value=\"New Hampshire\" >New Hampshire</option>
		<option value=\"New Jersey\" >New Jersey</option>
		<option value=\"New Mexico\" >New Mexico</option>
		<option value=\"New York\" >New York</option>
		<option value=\"North Carolina\" >North Carolina</option>
		<option value=\"North Dakota\" >North Dakota</option>
		<option value=\"Ohio\" >Ohio</option>
		<option value=\"Oklahoma\" >Oklahoma</option>
		<option value=\"Oregon\" >Oregon</option>
		<option value=\"Pennsylvania\" >Pennsylvania</option>
		<option value=\"Rhode Island\" >Rhode Island</option>
		<option value=\"South Carolina\" >South Carolina</option>
		<option value=\"South Dakota\" >South Dakota</option>
		<option value=\"Tennessee\" >Tennessee</option>
		<option value=\"Texas\" >Texas</option>
		<option value=\"Utah\" >Utah</option>
		<option value=\"Vermont\" >Vermont</option>
		<option value=\"Virginia\" >Virginia</option>
		<option value=\"Washington\" >Washington</option>
		<option value=\"West Virginia\" >West Virginia</option>
		<option value=\"Wisconsin\" >Wisconsin</option>
		<option value=\"Wyoming\" >Wyoming</option>
	</select> <input name=\"zip\" type=\"text\" id=\"zip\" size=\"10\">

				
			  </td>

            </tr>
			<tr>
                <td class=\"mail_form_td_field_title\" colspan=\"2\">&nbsp;</td>
			</tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Email:</span></td>
                <td class=\"mail_form_td\"><input name=\"email\" type=\"text\" id=\"email\" size=\"50\" /> <span class=\"mail_form_large_text\" style=\"color:#F00;\"><b>*</b></span></td>
            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Email Confirm:</span></td>
                <td class=\"mail_form_td\"><input name=\"email_confirm\" type=\"text\" id=\"email_confirm\" size=\"50\" /> <span class=\"mail_form_large_text\" style=\"color:#F00;\"><b>*</b></span></td>

            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\" colspan=\"2\">&nbsp;</td>
            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Home Phone:</span></td>
                <td class=\"mail_form_td\"><input type=\"text\" name=\"home_phone\" id=\"home_phone\" /><input type=\"radio\" value=\"home\" name=\"preferred_phone\" id=\"preferred_phone[0]\" /><span class=\"mail_form_small_text\"> Preferred Phone</span></td>

            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Work Phone:</span></td>
                <td class=\"mail_form_td\"><input type=\"text\" name=\"work_phone\" id=\"work_phone\" /><input type=\"radio\" value=\"work\" name=\"preferred_phone\" id=\"preferred_phone[1]\" /><span class=\"mail_form_small_text\"> Preferred Phone</span></td>
            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Cell Phone:</span></td>

                <td class=\"mail_form_td\"><input type=\"text\" name=\"cell_phone\" id=\"cell_phone\" /><input type=\"radio\" value=\"cell\" name=\"preferred_phone\" id=\"preferred_phone[2]\" /><span  class=\"mail_form_small_text\"> Preferred Phone</span></td>
            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Best time to call:
                </span></td>
                <td class=\"mail_form_td\">
                <div id=\"best_time\">
                <input type=\"radio\" name=\"best_time\" id=\"best_time[0]\" value=\"day\" /><span class=\"mail_form_large_text\">Day</span> 
                <input type=\"radio\" name=\"best_time\" id=\"best_time[1]\" value=\"evening\" /><span class=\"mail_form_large_text\">Evening</span>
                </div>
                </td>
            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\" colspan=\"2\">&nbsp;</td>
            </tr>
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Comments:</span></td>
                <td class=\"mail_form_td\"><textarea name=\"comments\" id=\"comments\" rows=\"5\" cols=\"50\"></textarea></td>
            </tr>
          <!--
            <tr>
                <td class=\"mail_form_td_field_title\"><span class=\"mail_form_large_text\">Select file to upload:</span></td>
                <td class=\"mail_form_td\"><input type=\"file\" name=\"upload_file\" id=\"upload_file\" /></td>
            </tr>
		-->
            <tr id=\"recaptcha_row\">
            	<td>&nbsp;</td>
            	<td id=\"recaptcha_td\">
                  <script type=\"text/javascript\" src=\"https://www.google.com/recaptcha/api/challenge?k=6LeGudMSAAAAAOkRJtut9PVOFIxedHgutbY-i1XT\" id=\"recaptcha_script\"></script>
				  <noscript>
					 <iframe src=\"https://www.google.com/recaptcha/api/noscript?k=6LeGudMSAAAAAOkRJtut9PVOFIxedHgutbY-i1XT\"
						 height=\"300\" width=\"500\" frameborder=\"0\" id=\"captcha_iframe\"></iframe><br>
					 <textarea name=\"recaptcha_challenge_field\" rows=\"3\" cols=\"40\">
					 </textarea>
					 <input type=\"hidden\" name=\"recaptcha_response_field\" id=\"recaptcha_response_field\" value=\"manual_challenge\">
				  </noscript>
               </td>
            </tr>
            <tr id=\"recaptcha2_row\">
              	<td>&nbsp;</td>
            	<td id=\"recaptcha2_td\">
                  <div class=\"g-recaptcha\" data-sitekey=\"\" id=\"recaptcha2_div\"></div>
                  <script type=\"text/javascript\" src=\"https://www.google.com/recaptcha/api.js?hl=en\"></script>
          		</td>
          	</tr>
            <tr id=\"wscaptcha_row\">
                <td>&nbsp;</td>
                <td class=\"mail_form_td_field_title\" style=\"vertical-align: bottom;\">
                  <table>
                  <tr>
                  <td width=\"200\">
                  <img alt=\"wspcaptcha\" border=\"0\" id=\"wspcaptcha\" src=\"wspcaptcha.php\" /> 
                  </td>
                  <td valign=\"bottom\" align=\"left\" width=\"100%\">
                  <a href=\"javascript:void(0);\" onclick=\"document.getElementById(\'wspcaptcha\').src=\'wspcaptcha.php?t=\'+(new Date()).getTime(); return false;\">
                  <img alt=\"Reload\" border=\"0\" src=\"/images/reload.gif\" /></a>
                  </td>
                  </tr>
                  <tr>
                  <td class=\"mail_form_td_field_title\" style=\"vertical-align: bottom;\" colspan=\"2\">
                  <input name=\"wsp_code\" id=\"wsp_code\" style=\"width:120px;\" type=\"text\" value=\"\" class=\"text_box\" />
                  </td>
                  </tr>
                  <tr>
                  <td class=\"mail_form_td\" colspan=\"2\">
                  Type in the letters you see <span class=\"mail_form_large_text\"><span class=\"required_fields\"><b>*</b></span></span>
                  </td>
                  </table>
                </td>
            </tr>
            <tr id=\"mollomcaptcha_row\">
            	<td>&nbsp;</td>
            	<td align=\"left\">
                  <div id=\"mollom_captcha\">&nbsp;</div>
                  <input type=\"hidden\" name=\"mollom_session\" id=\"mollom_session\" />
                  <input type=\"text\" name=\"captcha_response_field\" id=\"captcha_response_field\" size=\"10\" value=\"\" autocomplete=\"off\" />
                  <span class=\"mail_form_small_text\">Type the characters you see in this picture</span>
               </td>
            </tr>
			<tr>
            	<td colspan=\"2\">
                  <table width=\"100%\" border=\"0\"><tr>
                    <td align=\"right\" width=\"55%\">
                    <div id=\"form_div_btn\" class=\"btn_div\" onClick=\"document.getElementById(\'frmMailForm\').submit();\"><span id=\"form_btn_txt\" class=\"btn_txt\">Submit</span></div>
                    </td>
                    <td align=\"right\"><span style=\"color:#F00;\"><span class=\"mail_form_large_text\"><b>*</b></span> <span class=\"mail_form_small_text\">required fields</span></span></td>
                  </tr></table>
            </tr>
        </tbody>
    </table>
    <input type=\"hidden\" name=\"redirect\" id=\"redirect\" value=\"/userfiles/file/contact_return.php\" />
    <input type=\"hidden\" name=\"subject\" id=\"subject\" value=\"Information Request\" />
    <input type=\"hidden\" name=\"from\" id=\"from\" value=\"no-reply@many-blessings.com\" />
    <input type=\"hidden\" name=\"recipient\" id=\"recipient\" value=\"\" />
    <input type=\"hidden\" name=\"email_required\" id=\"email_required\" value=\"1\" />
    <input type=\"hidden\" name=\"required_fields\" id=\"required_fields\" value=\"first_name\" />
    <input type=\"hidden\" name=\"html_message_page\" id=\"html_message_page\" value=\"contact_return_message\" />
    <input type=\"hidden\" name=\"table_name\" id=\"table_name\" value=\"contact_form\" />
    <input type=\"hidden\" name=\"use_captcha\" id=\"use_captcha\" value=\"1\" />
    <input type=\"hidden\" name=\"captcha_type\" id=\"captcha_type\" value=\"recaptcha2\" />
    <input id=\"alt_go_back\" name=\"alt_go_back\" type=\"hidden\" />
    <input id=\"redirect_err_to_src\" name=\"redirect_err_to_src\" type=\"hidden\" value=\"1\" />
  </div>
</form>
  </div>
  