
  
<div class="contact_form_wrapper">
  <!-- 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>
<div id="ErrImgResize" style="display: none;" class="form_submit_error_txt">
    There was an error resizing your image.  Please try again.
</div>
      
<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> 
 