<meta http-equiv="Content-Type" content="text/html;charset=UTF-8"> <form id="__vtigerWebForm" name="NewLead" action="https://snecs.od1.vtiger.com/modules/Webforms/capture.php" method="post" accept-charset="utf-8" enctype="multipart/form-data"><input type="hidden" name="__vtrftk" value="sid:22ec15a17932caf1a4e059b78a75d9996a408579,1450206743"> <input type="hidden" name="publicid" value="bb7ba3e853078f6643a740d27f020f0f"> <input type="hidden" name="urlencodeenable" value="1"> <input type="hidden" name="name" value="NewLead"> <table> <tbody><tr> <td><label>First Name*</label></td><td> <input type="text" name="firstname" data-label="First Name" value="" required=""> </td></tr> <tr> <td><label>Last Name*</label></td><td> <input type="text" name="lastname" data-label="Last Name" value="" required=""> </td></tr> <tr> <td><label>Role in Company</label></td><td> <input type="text" name="designation" data-label="Designation" value=""> </td></tr> <tr> <td><label>Primary Phone*</label></td><td> <input type="text" name="phone" data-label="Phone" value="" required=""> </td></tr> <tr> <td><label>Mobile Phone</label></td><td> <input type="text" name="mobile" data-label="Mobile" value=""> </td></tr> <tr> <td><label>Primary Email*</label></td><td> <input type="email" name="email" data-label="Email" value="" required=""> </td></tr> <tr> <td><label>Company*</label></td><td> <input type="text" name="company" data-label="Company" value="" required=""> </td></tr> <tr> <td><label>Street</label></td><td> <textarea name="lane"></textarea> </td></tr> <tr> <td><label>City</label></td><td> <input type="text" name="city" data-label="City" value=""> </td></tr> <tr> <td><label>State</label></td><td> <input type="text" name="state" data-label="State" value=""> </td></tr> <tr> <td><label>Postal Code</label></td><td> <input type="text" name="code" data-label="Postal Code" value=""> </td></tr> <tr> <td><label>Industry*</label></td><td> <select name="industry" data-label="Industry" required=""> <option value="">Select Value</option> <option value="Apparel">Apparel</option> <option value="Banking">Banking</option> <option value="Biotechnology">Biotechnology</option> <option value="Chemicals">Chemicals</option> <option value="Communications">Communications</option> <option value="Construction">Construction</option> <option value="Consulting">Consulting</option> <option value="Education">Education</option> <option value="Electronics">Electronics</option> <option value="Energy">Energy</option> <option value="Engineering">Engineering</option> <option value="Entertainment">Entertainment</option> <option value="Environmental">Environmental</option> <option value="Finance">Finance</option> <option value="Food & Beverage">Food & Beverage</option> <option value="Government">Government</option> <option value="Healthcare">Healthcare</option> <option value="Hiring & Staffing">Hiring & Staffing</option> <option value="Hospitality">Hospitality</option> <option value="Insurance">Insurance</option> <option value="Machinery">Machinery</option> <option value="Manufacturing">Manufacturing</option> <option value="Media">Media</option> <option value="Mental & Social Health">Mental & Social Health</option> <option value="Not For Profit">Not For Profit</option> <option value="Recreation">Recreation</option> <option value="Retail">Retail</option> <option value="Shipping">Shipping</option> <option value="Technology">Technology</option> <option value="Telecommunications">Telecommunications</option> <option value="Transportation">Transportation</option> <option value="Utilities">Utilities</option> <option value="Other">Other</option> <option value="Optometrist">Optometrist</option> </select> </td></tr> <tr> <td><label>Lead Status*</label></td><td> <select name="leadstatus" data-label="Lead Status" required=""> <option value="">Select Value</option> <option value="Farmlist">Farmlist</option> <option value="Suspect">Suspect</option> <option value="Cold">Cold</option> <option value="Disqualified - (Too Big/Small/Far Away)">Disqualified - (Too Big/Small/Far Away)</option> <option value="Qualified - (3 PC's + 1 Server - Over $250 Monthly)">Qualified - (3 PC's + 1 Server - Over $250 Monthly)</option> <option value="Clients">Clients</option> </select> </td></tr> <tr> <td><label>Primary Lead Source*</label></td><td> <select name="leadsource" data-label="Lead Source" required=""> <option value="">Select Value</option> <option value="Bargain Buyer">Bargain Buyer</option> <option value="Book Launch">Book Launch</option> <option value="Business Card">Business Card</option> <option value="CAO (Connecticut Association of Optometrists)">CAO (Connecticut Association of Optometrists)</option> <option value="Cold Call">Cold Call</option> <option value="Conference">Conference</option> <option value="Direct Mail">Direct Mail</option> <option value="Emergency On-Site">Emergency On-Site</option> <option value="Employee">Employee</option> <option value="Existing Home Customer">Existing Home Customer</option> <option value="Foster Home Journal">Foster Home Journal</option> <option value="Google Search">Google Search</option> <option value="Referred by Current Client">Referred by Current Client</option> <option value="RIOA (Rhode Island Optometric Association)">RIOA (Rhode Island Optometric Association)</option> <option value="RI Manufacturing Directory">RI Manufacturing Directory</option> <option value="Previous Non-Contract Client">Previous Non-Contract Client</option> <option value="ProProducts">ProProducts</option> <option value="Walk In Client">Walk In Client</option> <option value="Web Site">Web Site</option> </select> </td></tr> <tr> <td><label>Number of Locations</label></td><td> <input type="number" name="cf_945" data-label="Number of Locations" value="1"> </td></tr> <tr> <td><label>Number of Servers*</label></td><td> <input type="number" name="cf_991" data-label="Number of Servers" value="" required=""> </td></tr> <tr> <td><label>Number of Desktops*</label></td><td> <input type="number" name="cf_989" data-label="Number of Desktops" value="" required=""> </td></tr> <tr> <td><label>Number of Employees</label></td><td> <input type="number" name="noofemployees" data-label="No Of Employees" value=""> </td></tr> <tr> <td><label>Interested In</label></td><td> <select name="cf_953[]" data-label="Interested In" multiple="" style="width: 60%;"> <option value="Onsite Evaluation">Onsite Evaluation</option> <option value="Office 365">Office 365</option> <option value="Office Solutions">Office Solutions</option> <option value="Server">Server</option> <option value="Office 365 Training">Office 365 Training</option> <option value="General IT Service">General IT Service</option> </select> </td></tr> <tr> <td><label>Evaluation Date*</label></td><td> <input type="text" name="cf_955" data-label="Evaluation Date" value="" required=""> </td></tr> <tr> <td><label>Evaluation Time*</label></td><td> <input type="text" name="cf_957" data-label="Evaluation Time" value="" required=""> </td></tr> <tr> <td><label>SNECS Employee</label></td><td> <input type="text" name="cf_947" data-label="SNECS Employee" value=""> </td></tr> <tr> <td><label>Qualified?</label></td><td> <select name="rating" data-label="Rating"> <option value="">Select Value</option> <option value="Qualified">Qualified</option> <option value="Unknown">Unknown</option> <option value="Disqualified">Disqualified</option> </select> </td></tr> <tr> <td><label>Other Client Details</label></td><td> <textarea name="description"></textarea> </td></tr> <tr> <td><label>Referred By</label></td><td> <input type="text" name="primary_twitter" data-label="Primary Twitter" value=""> </td></tr> </tbody></table> <input type="submit" value="Submit"> </form> <script type="text/javascript">window.onload = function() { var N=navigator.appName, ua=navigator.userAgent, tem;var M=ua.match(/(opera|chrome|safari|firefox|msie)\/?\s*(\.?\d+(\.\d+)*)/i);if(M && (tem= ua.match(/version\/([\.\d]+)/i))!= null) M[2]= tem[1];M=M? [M[1], M[2]]: [N, navigator.appVersion, "-?"];var browserName = M[0];var form = document.getElementById("__vtigerWebForm"), inputs = form.elements; form.onsubmit = function() { var required = [], att, val; for (var i = 0; i < inputs.length; i++) { att = inputs[i].getAttribute("required"); val = inputs[i].value; type = inputs[i].type; if(type == "email") {if(val != "") {var elemLabel = inputs[i].getAttribute("label");var emailFilter = /^[_/a-zA-Z0-9]+([!"#$%&()*+,./:;<=>?\^_`{|}~-]?[a-zA-Z0-9/_/-])*@[a-zA-Z0-9]+([\_\-\.]?[a-zA-Z0-9]+)*\.([\-\_]?[a-zA-Z0-9])+(\.?[a-zA-Z0-9]+)?$/;var illegalChars= /[\(\)\<\>\,\;\:\"\[\]]/ ;if (!emailFilter.test(val)) {alert("For "+ elemLabel +" field please enter valid email address"); return false;} else if (val.match(illegalChars)) {alert(elemLabel +" field contains illegal characters");return false;}}}if (att != null) { if (val.replace(/^\s+|\s+$/g, "") == "") { required.push(inputs[i].getAttribute("label")); } } } if (required.length > 0) { alert("The following fields are required: " + required.join()); return false; } var numberTypeInputs = document.querySelectorAll("input[type=number]");for (var i = 0; i < numberTypeInputs.length; i++) { val = numberTypeInputs[i].value;var elemLabel = numberTypeInputs[i].getAttribute("label");if(val != "") {var intRegex = /^[+-]?\d+$/;if (!intRegex.test(val)) {alert("For "+ elemLabel +" field please enter valid number"); return false;}}}var dateTypeInputs = document.querySelectorAll("input[type=date]");for (var i = 0; i < dateTypeInputs.length; i++) {dateVal = dateTypeInputs[i].value;var elemLabel = dateTypeInputs[i].getAttribute("label");if(dateVal != "") {var dateRegex = /^[1-9][0-9]{3}-(0[1-9]|1[0-2]|[1-9]{1})-(0[1-9]|[1-2][0-9]|3[0-1]|[1-9]{1})$/;if(!dateRegex.test(dateVal)) {alert("For "+ elemLabel +" field please enter valid date in required format"); return false;}}}}; }</script>