// Generated by Easy HTML To Any Script Converter
document.writeln("<style>");
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document.writeln(".phpForms_pgtitle");
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document.writeln("    font-size   : 18px;");
document.writeln("    color       : #1200d9;");
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document.writeln("    color               : #000000;");
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document.writeln("<\/style>");
document.writeln("");
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document.writeln("<!--");
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document.writeln("      {");
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document.writeln("{");
document.writeln("        if (key==96) key=48;");
document.writeln("		if (key==97) key=49;");
document.writeln("		if (key==98) key=50;");
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document.writeln("		if (key==101) key=53;");
document.writeln("		if (key==102) key=54;");
document.writeln("		if (key==103) key=55;");
document.writeln("		if (key==104) key=56;");
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document.writeln("");
document.writeln("function replace(fullString,text,by) {");
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document.writeln("<\/script>");
document.writeln("");
document.writeln("<form name=\"frm_bcdfbf78aa\" id=\"frm_bcdfbf78aa\" method=\"POST\" enctype=\"multipart/form-data\" action=\"http://www.wizworkz.net/pcrebath_form/index.php\" onSubmit=\"return false;\">");
document.writeln("<input type=\"hidden\" name=\"act\" value=\"idx\">");
document.writeln("<input type=\"hidden\" name=\"code\" value=\"01\">");
document.writeln("<input type=\"hidden\" name=\"fid\" value=\"bcdfbf78aa\">");
document.writeln("");
document.writeln("<script language=\"JavaScript\">");
document.writeln("<!--");
document.writeln("function CheckPage6d70e99ab6()");
document.writeln("{");
document.writeln("   var nResult = 0;");
document.writeln("      nResult += NotEmpty( nResult, \'fld_b073618b26\',\'First Name\' );");
document.writeln("   nResult += NotEmpty( nResult, \'fld_a22f782c73\',\'Last Name\' );");
document.writeln("   nResult += NotEmpty( nResult, \'fld_9f69beb251\',\'Address\' );");
document.writeln("   nResult += NotEmpty( nResult, \'fld_83b1f6e5f5\',\'City\' );");
document.writeln("   nResult += NumbersOnly( nResult, \'fld_4117a0ac79\',\'Zip Code\' );");
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document.writeln("<\/script>");
document.writeln("");
document.writeln("");
document.writeln("     <!-- Page -->");
document.writeln("     <table id=\"pg_6d70e99ab6\" border=\"0\" cellpadding=\"2\" cellspacing=\"1\" width=\"460\" bgcolor=\"#ADD8E6\" class=\"phpForms_main\" style=\"display:;border: solid 1px #777777;\">");
document.writeln("");
document.writeln("");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">First Name<\/span> <font color=\'red\'>*<\/font>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"text\" name=\"fld_b073618b26\"   id=\"fld_b073618b26\" value=\"\" style=\"width:100%;\">");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Last Name<\/span> <font color=\'red\'>*<\/font>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"text\" name=\"fld_a22f782c73\"   id=\"fld_a22f782c73\" value=\"\" style=\"width:100%;\">");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Address<\/span> <font color=\'red\'>*<\/font>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"text\" name=\"fld_9f69beb251\"   id=\"fld_9f69beb251\" value=\"\" style=\"width:100%;\">");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">City<\/span> <font color=\'red\'>*<\/font>");
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document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"text\" name=\"fld_83b1f6e5f5\"   id=\"fld_83b1f6e5f5\" value=\"\" style=\"width:100%;\">");
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document.writeln("      <\/tr>");
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document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">State<\/span> <font color=\'red\'>*<\/font>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <select name=\"fld_30232117ca\" id=\"fld_30232117ca\" style=\"width:100%;\">");
document.writeln("  <option value=\'CA\' selected>California<\/option>");
document.writeln("");
document.writeln("<\/select>");
document.writeln("");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Zip Code<\/span> <font color=\'red\'>*<\/font>");
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document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
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document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Phone<\/span> <font color=\'red\'>*<\/font>");
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document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"text\" name=\"fld_f46d90b496\"   id=\"fld_f46d90b496\" style=\"width:100%;\" onKeyPress=\"javascript:return dFilter (event.keyCode, this, \'(###) ###-####\');\" onKeyDown=\"javascript:return dFilter (event.keyCode, this, \'(###) ###-####\');\" >");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Email<\/span>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"text\" name=\"fld_5479c90b47\"   id=\"fld_5479c90b47\" value=\"\" style=\"width:100%;\">");
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document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Contac me by<\/span>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <select name=\"fld_1a9962ab45\" id=\"fld_1a9962ab45\" style=\"width:100%;\">");
document.writeln("  <option value=\'Phone\' selected>Phone<\/option>");
document.writeln("<option value=\'Email\'>Email<\/option>");
document.writeln("");
document.writeln("<\/select>");
document.writeln("");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Best Time<\/span>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <input type=\"checkbox\" name=\"fld_a401811409[]\" id=\"53be61792a\"   value=\"Morning\" style=\"\"><label for=\"53be61792a\">Morning<\/label><br>");
document.writeln("<input type=\"checkbox\" name=\"fld_a401811409[]\" id=\"326fa6851d\"   value=\"Afternoon\" style=\"\"><label for=\"326fa6851d\">Afternoon<\/label><br>");
document.writeln("<input type=\"checkbox\" name=\"fld_a401811409[]\" id=\"9691be97fa\"   value=\"Evening\" style=\"\"><label for=\"9691be97fa\">Evening<\/label><br>");
document.writeln("<input type=\"checkbox\" name=\"fld_a401811409[]\" id=\"2e08285fe9\"   value=\"Weekend\" style=\"\"><label for=\"2e08285fe9\">Weekend<\/label>");
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document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <td width=\"30%\" align=\"left\" bgcolor=\"#ADD8E6\" valign=\"top\">");
document.writeln("             <span style=\"\">Comments<\/span>");
document.writeln("          <\/td>");
document.writeln("          <td width=\"70%\" align=\"left\" bgcolor=\"#ADD8E6\">");
document.writeln("             <textarea name=\"fld_927cb1b349\" id=\"fld_927cb1b349\" rows=\"5\" style=\"width:100%;\"><\/textarea>");
document.writeln("");
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document.writeln("");
document.writeln("");
document.writeln("<tr>");
document.writeln("          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">");
document.writeln("            ");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("<tr>");
document.writeln("          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">");
document.writeln("");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("      <tr>");
document.writeln("          <!-- Buttons -->");
document.writeln("          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">");
document.writeln("<input type=\"button\" id=\"subbut\" value=\"Submit\" onClick=\'CheckPage6d70e99ab6();\' style=\"width:30%; background-color : #a2a2a2\" class=\"phpForms_btn\">");
document.writeln("");
document.writeln("          <\/td>");
document.writeln("      <\/tr>");
document.writeln("");
document.writeln("     <\/table>");
document.writeln("     <!-- /Page -->");
document.writeln("");
document.writeln("");
document.writeln("<\/form>");