tag:blogger.com,1999:blog-72381858440119365382024-03-13T14:31:14.197-07:00Order FormARCHSTARhttp://www.blogger.com/profile/17485691540378034508noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-7238185844011936538.post-48405451052765018102010-05-07T07:44:00.001-07:002011-09-08T04:43:08.652-07:00Order Form<f <link="" href="http://www.emailmeform.com/builder/styles/dynamic.php?t=post" rel="stylesheet" type="text/css">
<link href="http://www.emailmeform.com/builder/theme_css/02dldQU7TWVAM05u6" rel="stylesheet" type="text/css"></link>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.4.4/jquery.min.js" type="text/javascript">
</script>
<script type="text/javascript">
if (typeof jQuery == 'undefined'){
document.write(unescape("%3Cscript src='http://www.emailmeform.com/builder/js/jquery-1.4.4.min.js' type='text/javascript'%3E%3C/script%3E"));
}
</script>
<script src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.7.2/jquery-ui.min.js" type="text/javascript">
</script>
<script type="text/javascript">
if (typeof $.ui == 'undefined'){
document.write(unescape("%3Cscript src='http://www.emailmeform.com/builder/js/jquery-ui-1.7.2.custom.min.js' type='text/javascript'%3E%3C/script%3E"));
}
</script>
<script src="http://www.emailmeform.com/builder/js/dynamic.php?t=post&t2=0&use_CDN=true" type="text/javascript">
</script>
</f><br />
<form action="http://www.emailmeform.com/builder/form/02dldQU7TWVAM05u6" enctype="multipart/form-data" id="emf-form" method="post" name="emf-form">
<table bgcolor="#FFFFFF" border="0" cellpadding="2" cellspacing="0" style="text-align: left;">
<tbody>
<tr>
<td colspan="2"><br /><br /></td>
</tr>
<tr valign="top">
<td align="left" id="td_element_label_0"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Name</b></span> <span style="color: red;"><small>*</small></span>
</td>
<td id="td_element_field_0"><table border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td align="center" style="padding-left: 0; padding-right: 3px;"><input class="validate[required]" id="element_0_2" name="element_0[]" style="width: 60px;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">First</span>
</td>
<td align="center" style="padding-left: 0;"><input class="validate[required]" id="element_0_3" name="element_0[]" style="width: 100px;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">Last</span>
</td>
</tr>
</tbody></table>
<div style="color: black; padding-bottom: 8px;">
</div>
</td>
</tr>
<tr valign="top">
<td align="left" id="td_element_label_1"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Email</b></span> <span style="color: red;"><small>*</small></span>
</td>
<td id="td_element_field_1"><input class="validate[required,custom[email]]" id="element_1" name="element_1" size="30" type="text" value="" />
<br />
<div style="color: black; padding-bottom: 8px;">
</div>
</td>
</tr>
<tr valign="top">
<td align="left" id="td_element_label_2"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Phone</b></span> <span style="color: red;"><small>*</small></span>
</td>
<td id="td_element_field_2"><input class="validate[required,custom[telephone]]" id="element_2" name="element_2" size="30" type="text" value="" />
<br />
<div style="color: black; padding-bottom: 8px;">
<small><span style="font-family: Verdana;">ex : +628568563822</span></small>
</div>
</td>
</tr>
<tr valign="top">
<td align="left" id="td_element_label_3"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Item code & Quantity</b></span> <span style="color: red;"><small>*</small></span>
</td>
<td id="td_element_field_3"><textarea class="validate[required]" cols="60" id="element_3" name="element_3" rows="5"></textarea>
<br />
<div style="color: black; padding-bottom: 8px;">
<small><span style="font-family: Verdana;">ex : t245 = 2 pcs</span></small>
</div>
</td>
</tr>
<tr valign="top">
<td align="left" id="td_element_label_4"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Shipping Address</b></span> <span style="color: red;"><small>*</small></span>
</td>
<td id="td_element_field_4"><table border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td colspan="2" style="padding-left: 0;"><input class="validate[required]" id="element_4_1" name="element_4[]" style="width: 99%;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">Street Address</span>
</td>
</tr>
<tr style="display: none;">
<td colspan="2" style="padding-left: 0;"><input class="validate[optional]" id="element_4_2" name="element_4[]" style="width: 99%;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">Address Line 2</span>
</td>
</tr>
<tr>
<td style="padding-left: 0; width: 50%;"><input class="validate[required]" id="element_4_3" name="element_4[]" style="width: 99%;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">City</span>
</td>
<td style="padding-left: 5px; width: 50%;"><input class="validate[required]" id="element_4_4" name="element_4[]" style="width: 99%;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">State / Province / Region</span>
</td>
</tr>
<tr>
<td style="padding-left: 0; width: 50%;"><input class="validate[required]" id="element_4_5" name="element_4[]" style="width: 99%;" type="text" value="" /><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">Postal / Zip Code</span>
</td>
<td style="padding-left: 5px; width: 50%;"><select class="validate[required]" id="element_4_6" name="element_4[]" style="width: 100%;">
<optgroup label="North America">
<option value="Antigua and Barbuda">
Antigua and Barbuda
</option>
<option value="Aruba,Bahamas">
Aruba,Bahamas
</option>
<option value="Barbados">
Barbados
</option>
<option value="Belize">
Belize
</option>
<option value="Canada">
Canada
</option>
<option value="Cook Islands">
Cook Islands
</option>
<option value="Costa Rica">
Costa Rica
</option>
<option value="Cuba">
Cuba
</option>
<option value="Dominica">
Dominica
</option>
<option value="Dominican Republic">
Dominican Republic
</option>
<option value="El Salvador">
El Salvador
</option>
<option value="Grenada">
Grenada
</option>
<option value="Guatemala">
Guatemala
</option>
<option value="Haiti">
Haiti
</option>
<option value="Honduras">
Honduras
</option>
<option value="Jamaica">
Jamaica
</option>
<option value="Mexico">
Mexico
</option>
<option value="Netherlands Antilles">
Netherlands Antilles
</option>
<option value="Nicaragua">
Nicaragua
</option>
<option value="Panama ">
Panama
</option>
<option value="Puerto Rico ">
Puerto Rico
</option>
<option value="Saint Kitts and Nevis">
Saint Kitts and Nevis
</option>
<option value="Saint Lucia">
Saint Lucia
</option>
<option value="Saint Vincent and the Grenadines">
Saint Vincent and the Grenadines
</option>
<option value="Trinidad and Tobago">
Trinidad and Tobago
</option>
<option value="United States">
United States
</option>
</optgroup>
<optgroup label="South America">
<option value="Argentina">
Argentina
</option>
<option value="Bolivia">
Bolivia
</option>
<option value="Brazil">
Brazil
</option>
<option value="Chile">
Chile
</option>
<option value="Colombia">
Colombia
</option>
<option value="Ecuador">
Ecuador
</option>
<option value="Guyana">
Guyana
</option>
<option value="Paraguay">
Paraguay
</option>
<option value="Peru">
Peru
</option>
<option value="Suriname">
Suriname
</option>
<option value="Uruguay">
Uruguay
</option>
<option value="Venezuela">
Venezuela
</option>
</optgroup>
<optgroup label="Europe">
<option value="Albania">
Albania
</option>
<option value="Andorra">
Andorra
</option>
<option value="Armenia">
Armenia
</option>
<option value="Austria">
Austria
</option>
<option value="Azerbaijan">
Azerbaijan
</option>
<option value="Belarus">
Belarus
</option>
<option value="Belgium">
Belgium
</option>
<option value="Bosnia and Herzegovina">
Bosnia and Herzegovina
</option>
<option value="Bulgaria">
Bulgaria
</option>
<option value="Croatia">
Croatia
</option>
<option value="Cyprus">
Cyprus
</option>
<option value="Czech Republic">
Czech Republic
</option>
<option value="Denmark">
Denmark
</option>
<option value="Estonia">
Estonia
</option>
<option value="Faroe Islands">
Faroe Islands
</option>
<option value="Finland">
Finland
</option>
<option value="France">
France
</option>
<option value="Georgia">
Georgia
</option>
<option value="Germany">
Germany
</option>
<option value="Greece">
Greece
</option>
<option value="Hungary">
Hungary
</option>
<option value="Iceland">
Iceland
</option>
<option value="Ireland">
Ireland
</option>
<option value="Italy">
Italy
</option>
<option value="Latvia">
Latvia
</option>
<option value="Liechtenstein">
Liechtenstein
</option>
<option value="Lithuania">
Lithuania
</option>
<option value="Luxembourg">
Luxembourg
</option>
<option value="Macedonia">
Macedonia
</option>
<option value="Malta">
Malta
</option>
<option value="Moldova">
Moldova
</option>
<option value="Monaco">
Monaco
</option>
<option value="Montenegro">
Montenegro
</option>
<option value="Netherlands">
Netherlands
</option>
<option value="Norway">
Norway
</option>
<option value="Poland">
Poland
</option>
<option value="Portugal">
Portugal
</option>
<option value="Romania">
Romania
</option>
<option value="San Marino">
San Marino
</option>
<option value="Serbia">
Serbia
</option>
<option value="Slovakia">
Slovakia
</option>
<option value="Slovenia">
Slovenia
</option>
<option value="Spain">
Spain
</option>
<option value="Sweden">
Sweden
</option>
<option value="Switzerland">
Switzerland
</option>
<option value="Ukraine">
Ukraine
</option>
<option value="United Kingdom">
United Kingdom
</option>
<option value="Vatican City">
Vatican City
</option>
</optgroup>
<optgroup label="Asia">
<option value="Afghanistan">
Afghanistan
</option>
<option value="Bahrain">
Bahrain
</option>
<option value="Bangladesh">
Bangladesh
</option>
<option value="Bhutan">
Bhutan
</option>
<option value="Brunei Darussalam">
Brunei Darussalam
</option>
<option value="Myanmar">
Myanmar
</option>
<option value="Cambodia">
Cambodia
</option>
<option value="China">
China
</option>
<option value="East Timor">
East Timor
</option>
<option value="Hong Kong">
Hong Kong
</option>
<option value="India">
India
</option>
<option value="Indonesia">
Indonesia
</option>
<option value="Iran">
Iran
</option>
<option value="Iraq">
Iraq
</option>
<option value="Israel">
Israel
</option>
<option value="Japan">
Japan
</option>
<option value="Jordan">
Jordan
</option>
<option value="Kazakhstan">
Kazakhstan
</option>
<option value="North Korea">
North Korea
</option>
<option value="South Korea">
South Korea
</option>
<option value="Kuwait">
Kuwait
</option>
<option value="Kyrgyzstan">
Kyrgyzstan
</option>
<option value="Laos">
Laos
</option>
<option value="Lebanon">
Lebanon
</option>
<option value="Malaysia">
Malaysia
</option>
<option value="Maldives">
Maldives
</option>
<option value="Mongolia">
Mongolia
</option>
<option value="Nepal">
Nepal
</option>
<option value="Oman">
Oman
</option>
<option value="Pakistan">
Pakistan
</option>
<option value="Palestine">
Palestine
</option>
<option value="Philippines">
Philippines
</option>
<option value="Qatar">
Qatar
</option>
<option value="Russia">
Russia
</option>
<option value="Saudi Arabia">
Saudi Arabia
</option>
<option value="Singapore">
Singapore
</option>
<option value="Sri Lanka">
Sri Lanka
</option>
<option value="Syria">
Syria
</option>
<option value="Taiwan">
Taiwan
</option>
<option value="Tajikistan">
Tajikistan
</option>
<option value="Thailand">
Thailand
</option>
<option value="Turkey">
Turkey
</option>
<option value="Turkmenistan">
Turkmenistan
</option>
<option value="United Arab Emirates">
United Arab Emirates
</option>
<option value="Uzbekistan">
Uzbekistan
</option>
<option value="Vietnam">
Vietnam
</option>
<option value="Yemen">
Yemen
</option>
</optgroup>
<optgroup label="Oceania">
<option value="Australia">
Australia
</option>
<option value="Fiji">
Fiji
</option>
<option value="Kiribati">
Kiribati
</option>
<option value="Marshall Islands">
Marshall Islands
</option>
<option value="Micronesia">
Micronesia
</option>
<option value="Nauru">
Nauru
</option>
<option value="New Zealand">
New Zealand
</option>
<option value="Palau">
Palau
</option>
<option value="Papua New Guinea">
Papua New Guinea
</option>
<option value="Samoa">
Samoa
</option>
<option value="Solomon Islands">
Solomon Islands
</option>
<option value="Tonga">
Tonga
</option>
<option value="Tuvalu">
Tuvalu
</option>
<option value="Vanuatu">
Vanuatu
</option>
</optgroup>
<optgroup label="Africa">
<option value="Algeria">
Algeria
</option>
<option value="Angola">
Angola
</option>
<option value="Benin">
Benin
</option>
<option value="Botswana">
Botswana
</option>
<option value="Burkina Faso">
Burkina Faso
</option>
<option value="Burundi">
Burundi
</option>
<option value="Cameroon">
Cameroon
</option>
<option value="Cape Verde">
Cape Verde
</option>
<option value="Central African Republic">
Central African Republic
</option>
<option value="Chad">
Chad
</option>
<option value="Comoros">
Comoros
</option>
<option value="Democratic Republic of the Congo">
Democratic Republic of the Congo
</option>
<option value="Republic of the Congo">
Republic of the Congo
</option>
<option value="Djibouti">
Djibouti
</option>
<option value="Egypt">
Egypt
</option>
<option value="Equatorial Guinea">
Equatorial Guinea
</option>
<option value="Eritrea">
Eritrea
</option>
<option value="Ethiopia">
Ethiopia
</option>
<option value="Gabon">
Gabon
</option>
<option value="Gambia">
Gambia
</option>
<option value="Ghana">
Ghana
</option>
<option value="Gibraltar">
Gibraltar
</option>
<option value="Guinea">
Guinea
</option>
<option value="Guinea-Bissau">
Guinea-Bissau
</option>
<option value="Cote d'Ivoire">
Cote d'Ivoire
</option>
<option value="Kenya">
Kenya
</option>
<option value="Lesotho">
Lesotho
</option>
<option value="Liberia">
Liberia
</option>
<option value="Libya">
Libya
</option>
<option value="Madagascar">
Madagascar
</option>
<option value="Malawi">
Malawi
</option>
<option value="Mali">
Mali
</option>
<option value="Mauritania">
Mauritania
</option>
<option value="Mauritius">
Mauritius
</option>
<option value="Morocco">
Morocco
</option>
<option value="Mozambique">
Mozambique
</option>
<option value="Namibia">
Namibia
</option>
<option value="Niger">
Niger
</option>
<option value="Nigeria">
Nigeria
</option>
<option value="Rwanda">
Rwanda
</option>
<option value="Sao Tome and Principe">
Sao Tome and Principe
</option>
<option value="Senegal">
Senegal
</option>
<option value="Seychelles">
Seychelles
</option>
<option value="Sierra Leone">
Sierra Leone
</option>
<option value="Somalia">
Somalia
</option>
<option value="South Africa">
South Africa
</option>
<option value="Sudan">
Sudan
</option>
<option value="Swaziland">
Swaziland
</option>
<option value="United Republic of Tanzania">
United Republic of Tanzania
</option>
<option value="Togo">
Togo
</option>
<option value="Tunisia">
Tunisia
</option>
<option value="Uganda">
Uganda
</option>
<option value="Zambia">
Zambia
</option>
<option value="Zimbabwe">
Zimbabwe
</option>
</optgroup>
</select><br />
<span style="color: black; font-family: Verdana; font-size: x-small;">Country</span>
</td>
</tr>
</tbody></table>
<div style="color: black; padding-bottom: 8px;">
</div>
</td>
</tr>
<tr valign="top">
<td align="left" id="td_element_label_5"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Payment Method</b></span> <span style="color: red;"><small>*</small></span>
</td>
<td id="td_element_field_5"><div style="padding-bottom: 5px; width: 100%;">
<input class="validate[required]" id="element_5_0" name="element_5[]" type="checkbox" value="BCA" /><span style="color: black; font-family: Verdana; font-size: x-small;"> BCA </span>
</div>
<div style="padding-bottom: 5px; width: 100%;">
<input class="validate[required]" id="element_5_1" name="element_5[]" type="checkbox" value="Mandiri" /><span style="color: black; font-family: Verdana; font-size: x-small;"> Mandiri </span>
</div>
<div style="padding-bottom: 5px; width: 100%;">
<input class="validate[required]" id="element_5_2" name="element_5[]" type="checkbox" value="Paypal (coming soon)" /><span style="color: black; font-family: Verdana; font-size: x-small;"> Paypal (coming
soon) </span>
</div>
<div style="clear: both;">
</div>
<div style="color: black; padding-bottom: 8px;">
</div>
</td>
</tr>
<tr>
<td colspan="2"><table bgcolor="#E4F8E4" cellpadding="5" cellspacing="0">
<tbody>
<tr bgcolor="#AAD6AA">
<td colspan="2"><span style="color: white; font-family: Verdana; font-size: x-small;"><b>Image Verification</b></span>
</td>
</tr>
<tr>
<td style="padding: 2px; width: 100px;"><img alt="captcha" id="captcha_image" name="captcha_image" src="http://www.emailmeform.com/builder/captcha/index/4e3b00bd767d6257766a65317c285aa4" />
</td>
<td valign="top"><div>
<span style="color: black;">Please enter the text from the image</span>:<br />
<input class="validate[required,funcCall[valid_captcha]]" id="captcha_code" maxlength="10" name="captcha_code" size="10" type="text" /> [<a href="javascript:void(0);" id="captcha_code_refresh" name="captcha_code_refresh">Refresh Image</a>] [<a href="javascript:void(0);" id="captcha_code_about" name="captcha_code_about">What's This?</a>]
</div>
</td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td align="right" colspan="2"><input name="element_counts" type="hidden" value="6" /> <input name="embed" type="hidden" value="forms" /><input type="submit" value="Send email" /><input type="reset" value="Clear" />
</td>
</tr>
</tbody></table>
</form>
<br />
<div style="text-align: left;">
<span style="color: black; font-family: Verdana; font-size: x-small;">Powered by</span><span style="bottom: -5px; padding-left: 3px; position: relative;"><img src="http://www.emailmeform.com/builder/images/footer-logo.png" /></span><span style="color: black; font-family: Verdana; font-size: x-small;">EMF</span> <a href="http://www.emailmeform.com/" style="text-decoration: none;" target="_blank"><span style="color: black; font-family: Verdana; font-size: x-small;">Web Forms Builder</span></a><br />
<a href="http://www.emailmeform.com/report-abuse.html?http://www.emailmeform.com/builder/form/02dldQU7TWVAM05u6" style="font-size: 70%; line-height: 20px; text-decoration: none;" target="_blank"><span style="color: black; font-family: Verdana; font-size: x-small;">Report Abuse</span></a>
</div>
<script type="text/javascript">
//<![CDATA[
var EMF_Safari_Captcha = (function(){
this.isChrome = (/chrome/.test(navigator.userAgent.toLowerCase()));
this.isSafari = !this.isChrome && (/safari/.test(navigator.userAgent.toLowerCase()));
this.process_captcha = function(){
EMF_jQuery('a#captcha_code_refresh').trigger('click');
get_valid_captcha();
}
this.firstTimeSession = true;
this.safari_submit_session_form = function(){
if (this.firstTimeSession) {
this.firstTimeSession = false;
EMF_jQuery("#safari_sessionform").submit();
setTimeout('process_captcha()',2000);
}
}
return this;
})();
EMF_jQuery(function(){
EMF_jQuery("#emf-form").validationEngine({
validationEventTriggers:"blur",
scroll:true
});
if(document.getElementById('captcha_image')!=null){
if(EMF_Safari_Captcha.isSafari){
EMF_jQuery("body").append('<iframe id="safari_sessionframe" name="safari_sessionframe" onload="EMF_Safari_Captcha.safari_submit_session_form();" src="http://www.emailmeform.com/get_safari_cookies.php" style="display:none;"><\/iframe><form id="safari_sessionform" enctype="application/x-www-form-urlencoded" action="http://www.emailmeform.com/get_safari_cookies.php" target="safari_sessionframe" action="post">
<\/form>');
}else{
get_valid_captcha();
}
}
EMF_jQuery("#emf-form ul li").mousedown(highlight_field_on_mousedown);
EMF_jQuery("#emf-form ul li input, #emf-form ul li textarea, #emf-form ul li select").focus(highlight_field_on_focus);
var form_obj=EMF_jQuery("#emf-container form");
if(form_obj.length>0 && form_obj.attr('action').indexOf('#')==-1){
form_obj.attr('action', form_obj.attr('action')+document.location.hash);
}
});
EMF_jQuery(window).load(function(){
var parent_url = decodeURIComponent(document.location.hash.replace(/^#/, ''));
XD.postMessage(get_frame_height(), parent_url, parent);
});
//]]>
</script>ARCHSTARhttp://www.blogger.com/profile/17485691540378034508noreply@blogger.com