<?php
session_start();
$first_name_error = "";
$last_name_error = "";
$email_error = "";
$phone_number_error = "";
$street_address_error = "";
$city_error = "";
$state_error = "";
$zip_error = "";
$country_error = "";
$about_AAD_error = "";
$isAnythingSet = 0;
if (isset($_POST['Title'])) {
	$_SESSION['Title'] = $_POST['Title'];
    $isAnythingSet++;
}
if (isset($_POST['PhoneType'])) {
	$_SESSION['PhoneType'] = $_POST['PhoneType'];
    $isAnythingSet++;    
}
if (isset($_POST['BestToCall'])) {
	$_SESSION['BestToCall'] = $_POST['BestToCall'];
    $isAnythingSet++;   
}
if (isset($_POST['State'])) {
	$_SESSION['State'] = $_POST['State'];
    $isAnythingSet++;    
}
if (isset($_POST['AmputationLeve'])) {
	$_SESSION['AmputationLeve'] = $_POST['AmputationLeve'];
    $isAnythingSet++;
}
if (isset($_POST['CurrentProsthesis'])) {
	$_SESSION['CurrentProsthesis'] = $_POST['CurrentProsthesis'];
    $isAnythingSet++;
}
if (isset($_POST['TypesOfProsthesis'])) {
	$_SESSION['TypesOfProsthesis'] = $_POST['TypesOfProsthesis'];
    $isAnythingSet++;
}
if (isset($_POST['RequestDescription'])) {
	$_SESSION['RequestDescription'] = $_POST['RequestDescription'];
    $isAnythingSet++;
}
if (isset($_POST['RespondToRequest'])) {
	$_SESSION['RespondToRequest'] = $_POST['RespondToRequest'];
    $isAnythingSet++;
}
if (isset($_POST['AdditionalComments'])) {
	$_SESSION['AdditionalComments'] = $_POST['AdditionalComments'];
    $isAnythingSet++;
}
if (isset($_POST['FirstName'])) {
	if ($_POST['FirstName'] == "") {
    	$first_name_error = "Please enter first name";       
    }
    else {
    	$_SESSION['FirstName'] = $_POST['FirstName'];
    	$isAnythingSet++;          
    }
}
if (isset($_POST['LastName'])) {
	if ($_POST['LastName'] == "") {
    	$last_name_error = "Please enter last name"; 
    }
    else {
    	$_SESSION['LastName'] = $_POST['LastName'];
    	$isAnythingSet++;          
    }    
}
if (isset($_POST['eMail'])) {
	if ($_POST['eMail'] == "") {
    	$email_error = "Please enter e-mail"; 
    }
    else {
    	$_SESSION['eMail'] = $_POST['eMail'];
    	$isAnythingSet++;          
    }     
}
if (isset($_POST['PhoneNumber'])) {
	if ($_POST['PhoneNumber'] == "") {
    	$phone_number_error = "Please enter Phone Number"; 
    }
    else {
    	$_SESSION['PhoneNumber'] = $_POST['PhoneNumber'];
    	$isAnythingSet++;          
    } 
}    
if (isset($_POST['StreetAddress'])) {
	if ($_POST['StreetAddress'] == "") {
    	$street_address_error = "Please enter Street Address"; 
    }
    else {
    	$_SESSION['StreetAddress'] = $_POST['StreetAddress'];
    	$isAnythingSet++;          
    }     
}
if (isset($_POST['City'])) {
	if ($_POST['City'] == "") {
    	$city_error = "Please enter City"; 
    }
    else {
    	$_SESSION['City'] = $_POST['City'];
    	$isAnythingSet++;          
    }     
}
if (isset($_POST['Zip'])) {
	if ($_POST['Zip'] == "") {
    	$zip_error = "Please enter Zip"; 
    }
    else {
    	$_SESSION['Zip'] = $_POST['Zip'];
    	$isAnythingSet++;          
    }     
}
if (isset($_POST['Country'])) {
	if ($_POST['Country'] == "") {
    	$country_error = "Please enter Country"; 
    }
    else {
    	$_SESSION['Country'] = $_POST['Country'];
    	$isAnythingSet++;          
    }     
}
if (isset($_POST['AboutAAD'])) {
	if ($_POST['AboutAAD'] == "") {
    	$about_AAD_error = "Please select how you found us"; 
    }
    elseif ($_POST['AboutAAD'] == "Other") {
    	$_SESSION['AboutAAD'] = "Other: ".$_POST['PleaseList'];
    }
    else {
    	$_SESSION['AboutAAD'] = $_POST['AboutAAD'];
    	$isAnythingSet++;          
    }     
}
elseif (!$_POST) {
	$about_AAD_error = "";
}
else {
	$about_AAD_error = "Please select how you found us"; 
}
if ($isAnythingSet != 0 && $first_name_error == "" && $last_name_error == "" && $email_error == "" && $phone_number_error == "" && $street_address_error == "" && $city_error == "" && $state_error == "" && $zip_error == "" && $country_error == ""  && $about_AAD_error =="" ) {
	header("Location: contact.php"); 
} 
?>
<html><!-- InstanceBegin template="/Templates/index_nav.dwt" codeOutsideHTMLIsLocked="false" -->
<head>
<!-- InstanceBeginEditable name="doctitle" -->
<title>Advanced Arm Dynamics</title>
<!-- InstanceEndEditable --> 
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<!--Fireworks MX 2004 Dreamweaver MX 2004 target.  Created Fri May 19 16:20:08 GMT-0700 ( ) 2006-->
<script language="JavaScript" type="text/JavaScript">
<!--
function mmLoadMenus() {
  if (window.mm_menu_0519153527_11) return;
window.mm_menu_0519153527_11 = new Menu("root",260,25,"Verdana, Arial, Helvetica, sans-serif",10,"#ffffff","#FFFFFF","#6A90CE","#8C2F8A","left","middle",5,0,100,-5,7,true,false,true,5,true,false);
  mm_menu_0519153527_11.addMenuItem("Healthcare&nbsp;Professional&nbsp;Resource&nbsp;Center","location='healthC.html'");
  mm_menu_0519153527_11.addMenuItem("Patient&nbsp;Resource&nbsp;Center","location='patientRC.html'");
   mm_menu_0519153527_11.hideOnMouseOut=true;
   mm_menu_0519153527_11.bgColor='#ffffff';
   mm_menu_0519153527_11.menuBorder=0;
   mm_menu_0519153527_11.menuLiteBgColor='#ffffff';
   mm_menu_0519153527_11.menuBorderBgColor='#ffffff';
window.mm_menu_0519153527_0 = new Menu("root",118,25,"Verdana, Arial, Helvetica, sans-serif",10,"#ffffff","#FFFFFF","#6A90CE","#8C2F8A","left","middle",5,0,100,-5,7,true,false,true,5,true,false);
  mm_menu_0519153527_0.addMenuItem("Our&nbsp;Expertise","location='about_expertise.html'");
  mm_menu_0519153527_0.addMenuItem("Our&nbsp;Services","location='about_services.html'");
  mm_menu_0519153527_0.addMenuItem("Therapy","location='about_therapy.html'");
  mm_menu_0519153527_0.addMenuItem("Executive&nbsp;Bios","location='center_profile.html'");
   mm_menu_0519153527_0.hideOnMouseOut=true;
   mm_menu_0519153527_0.bgColor='#ffffff';
   mm_menu_0519153527_0.menuBorder=0;
   mm_menu_0519153527_0.menuLiteBgColor='#ffffff';
   mm_menu_0519153527_0.menuBorderBgColor='#ffffff';
    window.mm_menu_0519154441_0 = new Menu("root",241,25,"Verdana, Arial, Helvetica, sans-serif",10,"#ffffff","#FFFFFF","#6A90CE","#8C2F8A","left","middle",5,0,100,-5,7,true,false,true,5,true,false);
  mm_menu_0519154441_0.addMenuItem("Overview&nbsp;of&nbsp;Centers","location='center_overview.html'");
  mm_menu_0519154441_0.addMenuItem("Executive&nbsp;Bios","location='center_profile.html'");
  mm_menu_0519154441_0.addMenuItem("Center&nbsp;of&nbsp;Excellence&nbsp;Facility&nbsp;Tour","location='center_facility.html'");
  mm_menu_0519154441_0.addMenuItem("Virtual&nbsp;Tour&nbsp;of&nbsp;Centers","location='center_virtual.html'");
  mm_menu_0519154441_0.addMenuItem("Hospitality&nbsp;Center","location='center_hospitality.html'");
   mm_menu_0519154441_0.hideOnMouseOut=true;
   mm_menu_0519154441_0.bgColor='#ffffff';
   mm_menu_0519154441_0.menuBorder=0;
   mm_menu_0519154441_0.menuLiteBgColor='#ffffff';
   mm_menu_0519154441_0.menuBorderBgColor='#ffffff';
window.mm_menu_0519154704_0 = new Menu("root",127,25,"Verdana, Arial, Helvetica, sans-serif",10,"#ffffff","#FFFFFF","#6A90CE","#8C2F8A","left","middle",5,0,100,-5,7,true,false,true,5,true,false);
  mm_menu_0519154704_0.addMenuItem("Press&nbsp;Kit","location='news_pressKit.html'");
  mm_menu_0519154704_0.addMenuItem("Press&nbsp;Releases","location='news_press.html'");
  mm_menu_0519154704_0.addMenuItem("Media&nbsp;Coverage","location='news_mediaCoverage.html'");
  mm_menu_0519154704_0.addMenuItem("Media&nbsp;Contacts","location='news_mediaContacts.html'");
   mm_menu_0519154704_0.hideOnMouseOut=true;
   mm_menu_0519154704_0.bgColor='#ffffff';
   mm_menu_0519154704_0.menuBorder=0;
   mm_menu_0519154704_0.menuLiteBgColor='#ffffff';
   mm_menu_0519154704_0.menuBorderBgColor='#ffffff';

mm_menu_0519154704_0.writeMenus();
} // mmLoadMenus()

function MM_preloadImages() { //v3.0
  var d=document; if(d.images){ if(!d.MM_p) d.MM_p=new Array();
    var i,j=d.MM_p.length,a=MM_preloadImages.arguments; for(i=0; i<a.length; i++)
    if (a[i].indexOf("#")!=0){ d.MM_p[j]=new Image; d.MM_p[j++].src=a[i];}}
}

function MM_swapImgRestore() { //v3.0
  var i,x,a=document.MM_sr; for(i=0;a&&i<a.length&&(x=a[i])&&x.oSrc;i++) x.src=x.oSrc;
}

function MM_findObj(n, d) { //v4.01
  var p,i,x;  if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
    d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
  if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
  for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
  if(!x && d.getElementById) x=d.getElementById(n); return x;
}

function MM_swapImage() { //v3.0
  var i,j=0,x,a=MM_swapImage.arguments; document.MM_sr=new Array; for(i=0;i<(a.length-2);i+=3)
   if ((x=MM_findObj(a[i]))!=null){document.MM_sr[j++]=x; if(!x.oSrc) x.oSrc=x.src; x.src=a[i+2];}
}
//-->
</script>
<script language="JavaScript" src="mm_menu.js"></script>
<!-- InstanceBeginEditable name="head" -->
<style type="text/css">
<!--
.style4 {font-size: 10px}
-->
</style>
<script language="javascript">
function checkLongForm(){
	if(document.longForm.FirstName.value == '' || document.longForm.LastName.value == '' || document.longForm.eMail.value == '' || document.longForm.PhoneNumber.value == '' || document.longForm.StreetAddress.value == '' || document.longForm.City.value == '' || document.longForm.State.value == '' || document.longForm.Zip.value == '' || document.longForm.AboutAAD.value == ''){
			alert("Please fill in all the required fields.");
			return( false );
	}else{
			document.longForm.method = 'post';
			document.longForm.action = 'contact.php';
			document.longForm.submit();
			return( true );
		}
}
</script>
<style type="text/css">
<!--
.style5 {font-size: medium}
.notice {
	color:#FF0000;
	font-size:small;
}
-->
</style>
<!-- InstanceEndEditable --> 
<link href="aad.css" rel="stylesheet" type="text/css">
<style type="text/css">
<!--
a:link {
	color: 8C2F8A;
}
a:visited {
	color: 8C2F8A;
}
-->
</style>
</head>
<body bgcolor="#ffffff" onLoad="MM_preloadImages('images/nav_01about_ov.gif','images/nav_02new_ov.gif','images/nav_03center_ov.gif','images/nav_04newsroom_ov.gif','images/nav_05contact_ov.gif','images/nav_06sitemap_ov.gif','images/nav_0home_ov.gif')">
<script language="JavaScript1.2">mmLoadMenus();</script>
<table width="770" border="0" align="center" cellpadding="0" cellspacing="0">
  <!-- fwtable fwsrc="AAD_home_final.png" fwbase="index.gif" fwstyle="Dreamweaver" fwdocid = "1706674463" fwnested="0" -->
  <tr>
    <td><img src="images/spacer.gif" width="14" height="1" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="101" height="1" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="34" height="1" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="1" height="1" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="470" height="1" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="1" height="1" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="149" height="1" border="0" alt=""></td>
  </tr>
  <tr>
    <td colspan="7"><a href="index.html"><img name="logo" src="images/logo.gif" width="770" height="87" border="0" alt=""></a></td>
  </tr>
  <tr>
      
    <td colspan="3" valign="top"><a href="javascript:;" onMouseOver="MM_swapImage('nav_home','','images/nav_0home_ov.gif',1);MM_showMenu(window.mm_menu_0519153527_11,150,0,null,'nav_home')" onMouseOut="MM_swapImgRestore();MM_startTimeout()"></a><a href="home.html" onMouseOver="MM_swapImage('nav_home','','images/nav_0home_ov.gif',1);MM_showMenu(window.mm_menu_0519153527_11,150,0,null,'nav_home')" onMouseOut="MM_swapImgRestore();MM_startTimeout();"><img name="nav_home" src="images/nav_0home.gif" width="149" height="30" border="0" alt=""></a>
      <!--
	  <a href="../index.html" onMouseOver="MM_swapImage('nav_home1','','../images/nav_0home_ov.gif',1);MM_showMenu(window.mm_menu_0519153527_0,150,0,null,'nav_home')" onMouseOut="MM_swapImgRestore();MM_startTimeout()"></a><a href="../index.html" onMouseOver="MM_swapImage('nav_home','','../images/nav_0home_ov.gif',1);MM_showMenu(window.mm_menu_0519153527_0,150,0,null,'nav_home)" onMouseOut="MM_swapImgRestore();MM_startTimeout();"><img src="../images/nav_0home.gif" alt="" name="nav_home" width="149" height="30" border="0" id="nav_home"></a>
	  -->
    </td>
    <td rowspan="12"><img src="images/spacer.gif" width="1" height="513" border="0" alt=""></td>
    <td colspan="3" rowspan="12" valign="top"><!-- InstanceBeginEditable name="top" --> 
<table width="60" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <td rowspan="2"><img name="index_image" src="images/prc_image.jpg" width="470" height="287" border="0" alt=""></td>
    <td><img src="images/spacer.gif" width="1" height="1"></td>
    <td><a href="healthC.html"><img name="healthcare_thumb" src="images/healthcare_thumb.jpg" width="149" height="144" border="0" alt=""></a></td>
    <td><img src="images/spacer.gif" width="1" height="30"></td>
  </tr>
  <tr>
    <td><img src="images/spacer.gif" width="1" height="1"></td>
    <td><a href="patientRC.html"><img name="patient_thumb" src="images/patient_thumb.jpg" width="149" height="143" border="0" alt=""></a></td>
    <td><img src="images/spacer.gif" width="1" height="29"></td>
  </tr>
</table>
<!-- #BeginLibraryItem "/Library/patientRC_links.lbi" -->
<link href="aad.css" rel="stylesheet" type="text/css">
<table width="130" border="0" align="right" cellpadding="0" cellspacing="7">
  <tr valign="top">
    <td class="style2">&nbsp;</td>
    <td class="style2">&nbsp;</td>
  </tr>
  <tr valign="top">
    <td class="style2">&raquo;</td>
    <td class="sublink"><a href="patientRC.html">Patient Resource Center </a></td>
  </tr>
  <tr valign="top">
    <td class="style2">&raquo;</td>
    <td class="sublink"><a href="patientRC_why.html">Why Advanced Arm Dynamics</a></td>
  </tr>
  <tr valign="top">
    <td><span class="style2">&raquo;</span></td>
    <td class="sublink"><a href="patientRC_find.html">Finding a Prosthetist Tip Sheet </a></td>
  </tr>
  <tr valign="top">
    <td class="style2">&raquo;</td>
    <td class="sublink"><a href="patientRC_life.html">Life Within Reach Support Group</a> </td>
  </tr>
  <tr valign="top">
    <td><span class="style2">&raquo;</span></td>
    <td class="sublink"><a href="patientRC_testimonials.html">Patient Testimonials</a> </td>
  </tr>
  <tr valign="top">
    <td class="style2">&raquo;</td>
    <td class="sublink"><a href="patientRC_req.html">Request Information </a></td>
  </tr>
  <tr valign="top">
    <td><span class="style2">&raquo;</span></td>
    <td class="sublink"><a href="patientRC_advo.html">Advocacy Site Links </a></td>
  </tr>
  <tr valign="top">
    <td><span class="style2">&raquo;</span></td>
    <td class="sublink"><a href="resources_glossary.html">Glossary of Terms </a></td>
  </tr>
  <tr valign="top">
    <td><span class="style2">&raquo;</span></td>
    <td class="sublink"><a href="resources_related_web.html">Related Links </a></td>
  </tr>
  <tr valign="top">
    <td>&nbsp;</td>
    <td class="sublink">&nbsp;</td>
  </tr>
</table>
<!-- #EndLibraryItem --><table width="466" border="0" cellspacing="10" cellpadding="10">
      <tr>
        <td width="426"><img src="images/patientRC_request_h.gif" width="449" height="23"></td>
      </tr>
      <tr>
        <td valign="top"><p class="style2">We&rsquo;re always happy to answer any questions you might have regarding Advanced Arm Dynamics and/or how our Centers of Excellence can help you or a loved one. Please take a moment to fill out the form below &ndash; which will help us learn more about your individual needs.&nbsp; Additionally, you may also reach us toll free at 1-800-323-6422 to schedule a consultation.<br>
          <span class="footnote"> (NOTE: &nbsp;Your name and address will not be rented, sold or given to any third   party.)</span><br>
          <br>
          <em><font face="Arial, Helvetica, sans-serif"><span class="style4 style5 style6 style7 style5">*</span></font><font face="Arial, Helvetica, sans-serif" size="-3"> Indicates a Required Field</font></em></p>
	<!-- <form name="longForm" onSubmit="javascript:return checkLongForm()"> -->
<form name="longForm" action="" method="post">          
          <table width="433" border="0" cellspacing="0" cellpadding="3">
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">Title</span></td>
              <td><select name="Title" id="Title">
				  <option value="" <?php if ($_POST['Title'] == '') { echo 'selected="selected"'; } ?>></option>
                  <option value="Mr." <?php if ($_POST['Title'] == 'Mr.') { echo 'selected="selected"'; } ?>>Mr.</option>
                  <option value="Mrs." <?php if ($_POST['Title'] == 'Mrs.') { echo 'selected="selected"'; } ?>>Mrs.</option>
                  <option value="Ms." <?php if ($_POST['Title'] == 'Ms.') { echo 'selected="selected"'; } ?>>Ms.</option>
				  <option value="Miss." <?php if ($_POST['Title'] == 'Miss.') { echo 'selected="selected"'; } ?>>Miss.</option>
              </select></td>
            </tr>
            <tr>
              <td width="1">&nbsp;</td>
              <td width="100"><span class="style2">First Name</span><span class="style2">*</span></td>
              <td width="314">
                  <input name="FirstName" type="text" id="FirstName"value="<?php echo !empty($_POST['FirstName']) ? $_POST['FirstName'] : ""; ?>" /><span class="notice"><?php echo $first_name_error; ?></span>              </td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">Last Name*</span></td>
              <td>
                  <input name="LastName" type="text" id="LastName"value="<?php echo !empty($_POST['LastName']) ? $_POST['LastName'] : ""; ?>" /><span class="notice"><?php echo $last_name_error; ?></span>              </td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">E-mail*</span></td>
              <td>
                  <input name="eMail" type="text" id="eMail" value="<?php echo !empty($_POST['eMail']) ? $_POST['eMail'] : ""; ?>" /><span class="notice"><?php echo $email_error; ?></span>
                                </td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">Phone Number*</span></td>
              <td>
                  <input name="PhoneNumber" type="text" id="PhoneNumber" value="<?php echo !empty($_POST['PhoneNumber']) ? $_POST['PhoneNumber'] : ""; ?>" />
                  <select name="PhoneType" id="PhoneType">
                 <option value="Home" <?php if ($_POST['PhoneType'] == 'Home') { echo 'selected="selected"'; } ?>>Home</option>
                  <option value="Work" <?php if ($_POST['PhoneType'] == 'Work') { echo 'selected="selected"'; } ?>>Work</option>
                  <option value="Cell" <?php if ($_POST['PhoneType'] == 'Cell') { echo 'selected="selected"'; } ?>>Cell</option>
                </select><span class="notice"><?php echo $phone_number_error; ?></span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">Best Time to Call </span></td>
              <td><select name="BestToCall" id="BestToCall">
                <option value="Morning" <?php if ($_POST['BestToCall'] == 'Morning') { echo 'selected="selected"'; } ?>>Morning</option>
                <option value="Midday" <?php if ($_POST['BestToCall'] == 'Midday') { echo 'selected="selected"'; } ?>>Mid-day</option>
                <option value="Afternoon" <?php if ($_POST['BestToCall'] == 'Afternoon') { echo 'selected="selected"'; } ?>>Afternoon</option>
				<option value="Evening" <?php if ($_POST['BestToCall'] == 'Evening') { echo 'selected="selected"'; } ?>>Evening</option>
              </select></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">Street Address*</span></td>
              <td>
                  <input name="StreetAddress" type="text" id="StreetAddress" value="<?php echo !empty($_POST['StreetAddress']) ? $_POST['StreetAddress'] : ""; ?>" />  <span class="notice"><?php echo $street_address_error; ?></span>           </td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">City*</span></td>
              <td><input name="City" type="text" id="City" value="<?php echo !empty($_POST['City']) ? $_POST['City'] : ""; ?>" /> <span class="notice"><?php echo $city_error; ?></span>          </td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">State*</span></td>
              <td><select name="State" id="State">
                <option value=""></option>
                <option value="AL" <?php if ($_POST['State'] == 'AL') { echo 'selected="selected"'; } ?>>AL</option>
                <option value="AK" <?php if ($_POST['State'] == 'AK') { echo 'selected="selected"'; } ?>>AK</option>
                <option value="AS" <?php if ($_POST['State'] == 'AS') { echo 'selected="selected"'; } ?>>AS</option>
                <option value="AZ" <?php if ($_POST['State'] == 'AZ') { echo 'selected="selected"'; } ?>>AZ</option>
                <option value="AR" <?php if ($_POST['State'] == 'AR') { echo 'selected="selected"'; } ?>>AR</option>
                <option value="CA" <?php if ($_POST['State'] == 'CA') { echo 'selected="selected"'; } ?>>CA</option>
                <option value="CO" <?php if ($_POST['State'] == 'CO') { echo 'selected="selected"'; } ?>>CO</option>
                <option value="CT" <?php if ($_POST['State'] == 'CT') { echo 'selected="selected"'; } ?>>CT</option>
                <option value="DE" <?php if ($_POST['State'] == 'DE') { echo 'selected="selected"'; } ?>>DE</option>
                <option value="DC" <?php if ($_POST['State'] == 'DC') { echo 'selected="selected"'; } ?>>DC</option>
                <option value="FM" <?php if ($_POST['State'] == 'FM') { echo 'selected="selected"'; } ?>>FM</option>
                <option value="FL" <?php if ($_POST['State'] == 'FL') { echo 'selected="selected"'; } ?>>FL</option>
                <option value="GA" <?php if ($_POST['State'] == 'GA') { echo 'selected="selected"'; } ?>>GA</option>
                <option value="GU" <?php if ($_POST['State'] == 'GU') { echo 'selected="selected"'; } ?>>GU</option>
                <option value="HI" <?php if ($_POST['State'] == 'HI') { echo 'selected="selected"'; } ?>>HI</option>
                <option value="ID" <?php if ($_POST['State'] == 'ID') { echo 'selected="selected"'; } ?>>ID</option>
                <option value="IL" <?php if ($_POST['State'] == 'IL') { echo 'selected="selected"'; } ?>>IL</option>
                <option value="IN" <?php if ($_POST['State'] == 'IN') { echo 'selected="selected"'; } ?>>IN</option>
                <option value="IA" <?php if ($_POST['State'] == 'IA') { echo 'selected="selected"'; } ?>>IA</option>
                <option value="KS" <?php if ($_POST['State'] == 'KS') { echo 'selected="selected"'; } ?>>KS</option>
                <option value="KY" <?php if ($_POST['State'] == 'KY') { echo 'selected="selected"'; } ?>>KY</option>
                <option value="LA" <?php if ($_POST['State'] == 'LA') { echo 'selected="selected"'; } ?>>LA</option>
                <option value="ME" <?php if ($_POST['State'] == 'ME') { echo 'selected="selected"'; } ?>>ME</option>
                <option value="MH" <?php if ($_POST['State'] == 'MH') { echo 'selected="selected"'; } ?>>MH</option>
                <option value="MD" <?php if ($_POST['State'] == 'MD') { echo 'selected="selected"'; } ?>>MD</option>
                <option value="MA" <?php if ($_POST['State'] == 'MA') { echo 'selected="selected"'; } ?>>MA</option>
                <option value="MI" <?php if ($_POST['State'] == 'MI') { echo 'selected="selected"'; } ?>>MI</option>
                <option value="MN" <?php if ($_POST['State'] == 'MN') { echo 'selected="selected"'; } ?>>MN</option>
                <option value="MS" <?php if ($_POST['State'] == 'MS') { echo 'selected="selected"'; } ?>>MS</option>
                <option value="MO" <?php if ($_POST['State'] == 'MO') { echo 'selected="selected"'; } ?>>MO</option>
                <option value="MT" <?php if ($_POST['State'] == 'MT') { echo 'selected="selected"'; } ?>>MT</option>
                <option value="NE" <?php if ($_POST['State'] == 'NE') { echo 'selected="selected"'; } ?>>NE</option>
                <option value="NV" <?php if ($_POST['State'] == 'NV') { echo 'selected="selected"'; } ?>>NV</option>
                <option value="NH" <?php if ($_POST['State'] == 'NH') { echo 'selected="selected"'; } ?>>NH</option>
                <option value="NJ" <?php if ($_POST['State'] == 'NJ') { echo 'selected="selected"'; } ?>>NJ</option>
                <option value="NM" <?php if ($_POST['State'] == 'NM') { echo 'selected="selected"'; } ?>>NM</option>
                <option value="NY" <?php if ($_POST['State'] == 'NY') { echo 'selected="selected"'; } ?>>NY</option>
                <option value="NC" <?php if ($_POST['State'] == 'NC') { echo 'selected="selected"'; } ?>>NC</option>
                <option value="ND" <?php if ($_POST['State'] == 'ND') { echo 'selected="selected"'; } ?>>ND</option>
                <option value="MP" <?php if ($_POST['State'] == 'MP') { echo 'selected="selected"'; } ?>>MP</option>
                <option value="OH" <?php if ($_POST['State'] == 'OH') { echo 'selected="selected"'; } ?>>OH</option>
                <option value="OK" <?php if ($_POST['State'] == 'OK') { echo 'selected="selected"'; } ?>>OK</option>
                <option value="OR" <?php if ($_POST['State'] == 'OR') { echo 'selected="selected"'; } ?>>OR</option>
                <option value="PW" <?php if ($_POST['State'] == 'PW') { echo 'selected="selected"'; } ?>>PW</option>
                <option value="PA" <?php if ($_POST['State'] == 'PA') { echo 'selected="selected"'; } ?>>PA</option>
                <option value="PR" <?php if ($_POST['State'] == 'PR') { echo 'selected="selected"'; } ?>>PR</option>
                <option value="RI" <?php if ($_POST['State'] == 'RI') { echo 'selected="selected"'; } ?>>RI</option>
                <option value="SC" <?php if ($_POST['State'] == 'SC') { echo 'selected="selected"'; } ?>>SC</option>
                <option value="SD" <?php if ($_POST['State'] == 'SD') { echo 'selected="selected"'; } ?>>SD</option>
                <option value="TN" <?php if ($_POST['State'] == 'TN') { echo 'selected="selected"'; } ?>>TN</option>
                <option value="TX" <?php if ($_POST['State'] == 'TX') { echo 'selected="selected"'; } ?>>TX</option>
                <option value="UT" <?php if ($_POST['State'] == 'UT') { echo 'selected="selected"'; } ?>>UT</option>
                <option value="VT" <?php if ($_POST['State'] == 'VT') { echo 'selected="selected"'; } ?>>VT</option>
                <option value="VI" <?php if ($_POST['State'] == 'VI') { echo 'selected="selected"'; } ?>>VI</option>
                <option value="VA" <?php if ($_POST['State'] == 'VA') { echo 'selected="selected"'; } ?>>VA</option>
                <option value="WA" <?php if ($_POST['State'] == 'WA') { echo 'selected="selected"'; } ?>>WA</option>
                <option value="WV" <?php if ($_POST['State'] == 'WV') { echo 'selected="selected"'; } ?>>WV</option>
                <option value="WI" <?php if ($_POST['State'] == 'WI') { echo 'selected="selected"'; } ?>>WI</option>
                <option value="WY" <?php if ($_POST['State'] == 'WY') { echo 'selected="selected"'; } ?>>WY</option>
                <option value="AE" <?php if ($_POST['State'] == 'AE') { echo 'selected="selected"'; } ?>>AE</option>
                <option value="AA" <?php if ($_POST['State'] == 'AA') { echo 'selected="selected"'; } ?>>AA</option>
                <option value="AP" <?php if ($_POST['State'] == 'AP') { echo 'selected="selected"'; } ?>>AP</option>
              </select><span class="notice"><?php echo $state_error; ?></span>
              <span class="style2">ZIP*
                <input name="Zip" type="text" id="Zip" size="6" maxlength="6" value="<?php echo !empty($_POST['Zip']) ? $_POST['Zip'] : ""; ?>" />             
                </span> <span class="notice"><?php echo $zip_error; ?></span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td><span class="style2">Country</span></td>
              <td><select name="Country" id="Country">
			  	<option value="United States of America" selected>United States of America</option>
                <option value="Afghanistan">Afghanistan</option>
                <option value="Algeria">Algeria</option>
                <option value="American Samoa">American Samoa</option>
                <option value="Andorra">Andorra</option>
                <option value="Antigua/Barbuda">Antigua/Barbuda</option>
				<option value="Argentina">Argentina</option>
                <option value="Armenia">Armenia</option>
                <option value="Aruba">Aruba</option>
				<option value="Australia">Australia</option>
                <option value="Austria">Austria</option>
                <option value="Azerbaijan">Azerbaijan</option>
				<option value="Bahamas">Bahamas</option>
                <option value="Bahrain">Bahrain</option>
                <option value="Bangladesh">Bangladesh</option>
				<option value="Barbados">Barbados</option>
                <option value="Belarus">Belarus</option>
                <option value="Belgium">Belgium</option>
				<option value="Belize">Belize</option>
                <option value="Benin">Benin</option>
                <option value="Bermuda">Bermuda</option>
				<option value="Bhutan">Bhutan</option>
                <option value="Bolivia">Bolivia</option>
                <option value="Bosnia/Herzegovina">Bosnia/Herzegovina</option>
				<option value="Botswana">Botswana</option>
                <option value="Brazil">Brazil</option>
                <option value="British Virgin Islands">British Virgin Islands</option>
				<option value="Brunei Darussalam">Brunei Darussalam</option>
                <option value="Bulgaria">Bulgaria</option>
                <option value="Burkina Faso">Burkina Faso</option>
				<option value="Burundi">Burundi</option>
                <option value="Cambodia">Cambodia</option>
                <option value="Cameroon">Cameroon</option>
				<option value="Canada">Canada</option>
                <option value="Cape Verde">Cape Verde</option>
                <option value="Cayman Islands">Cayman Islands</option>
				<option value="Central African Republic">Central African Republic</option>
                <option value="Chad">Chad</option>
				<option value="Channel Islands">Channel Islands </option>
                <option value="Chile">Chile</option>
                <option value="China">China</option>
				<option value="Hong Kong (China)">Hong Kong (China)</option>
                <option value="Macao (China)">Macao (China)</option>
				<option value="Colombia">Colombia</option>
                <option value="Comoros">Comoros</option>
                <option value="Congo">Congo</option>
				<option value="Cook Islands">Cook Islands</option>
				<option value="Costa Rica">Costa Rica</option>
                <option value="C�te d'Ivoire">C�te d'Ivoire</option>
                <option value="Croatia">Croatia</option>
				<option value="Cuba">Cuba</option>
				<option value="Cyprus">Cyprus</option>
				<option value="Czech Republic">Czech Republic</option>
				<option value="Denmark">Denmark</option>
				<option value="Djibouti">Djibouti</option>
				<option value="Dominica">Dominica</option>
				<option value="Dominican Republic">Dominican Republic</option>
				<option value="Ecuador">Ecuador</option>
				<option value="Egypt">Egypt</option>
				<option value="El Salvador">El Salvador</option>
				<option value="Equatorial Guinea">Equatorial Guinea</option>
				<option value="Eritrea">Eritrea</option>
				<option value="Estonia">Estonia</option>
				<option value="Ethiopia">Ethiopia</option>
				<option value="Faeroe Islands">Faeroe Islands</option>
				<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
				<option value="Fiji">Fiji</option>
				<option value="Finland">Finland</option>
				<option value="France">France</option>
				<option value="French Guiana">French Guiana</option>
				<option value="French Polynesia">French Polynesia</option>
				<option value="Gabon">Gabon</option>
				<option value="Gambia">Gambia</option>
				<option value="Georgia">Georgia</option>
				<option value="Germany">Germany</option>
				<option value="Ghana">Ghana</option>
				<option value="Gibraltar">Gibraltar</option>
				<option value="Greece">Greece</option>
				<option value="Greenland">Greenland</option>
				<option value="Grenada">Grenada</option>
				<option value="Guadeloupe">Guadeloupe</option>
				<option value="Guam">Guam</option>
				<option value="Guatemala">Guatemala</option>
				<option value="Guernsey">Guernsey</option>
				<option value="Guinea">Guinea</option>
				<option value="Guinea-Bissau">Guinea-Bissau</option>
				<option value="Guyana">Guyana</option>
				<option value="Haiti">Haiti</option>
				<option value="Holy See">Holy See</option>
				<option value="Honduras">Honduras</option>
				<option value="Hungary">Hungary</option>
				<option value="Iceland">Iceland</option>
				<option value="India">India</option>
				<option value="Indonesia">Indonesia</option>
				<option value="Iran">Iran</option>
				<option value="Iraq">Iraq</option>
				<option value="Ireland">Ireland</option>
				<option value="Isle of Man">Isle of Man</option>
				<option value="Israel">Israel</option>
				<option value="Italy">Italy</option>
				<option value="Jamaica">Jamaica</option>
				<option value="Japan">Japan</option>
				<option value="Jordan">Jordan</option>
				<option value="Kazakhstan">Kazakhstan</option>
				<option value="Kenya">Kenya</option>
				<option value="Kiribati">Kiribati</option>
				<option value="Kuwait">Kuwait</option>
				<option value="Kyrgyzstan">Kyrgyzstan</option>
				<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
				<option value="Latvia">Latvia</option>
				<option value="Lebanon">Lebanon</option>
				<option value="Lesotho">Lesotho</option>
				<option value="Liberia">Liberia</option>
				<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
				<option value="Liechtenstein">Liechtenstein</option>
				<option value="Lithuania">Lithuania</option>
				<option value="Luxembourg">Luxembourg</option>
				<option value="Madagascar">Madagascar</option>
				<option value="Malawi">Malawi</option>
				<option value="Malaysia">Malaysia</option>
				<option value="Maldives">Maldives</option>
				<option value="Mali">Mali</option>
				<option value="Malta">Malta</option>
				<option value="Marshall Islands">Marshall Islands</option>
				<option value="Martinique">Martinique</option>
				<option value="Mauritania">Mauritania</option>
				<option value="Mauritius">Mauritius</option>
				<option value="Mayotte">Mayotte</option>
				<option value="Mexico">Mexico</option>
				<option value="Micronesia">Micronesia</option>
				<option value="Moldova">Moldova</option>
				<option value="Monaco">Monaco</option>
				<option value="Mongolia">Mongolia</option>
				<option value="Montenegro">Montenegro</option>
				<option value="Montserrat">Montserrat</option>
				<option value="Morocco">Morocco</option>
				<option value="Mozambique">Mozambique</option>
				<option value="Myanmar">Myanmar</option>
				<option value="Namibia">Namibia</option>
				<option value="Nauru">Nauru</option>
				<option value="Nepal">Nepal</option>
				<option value="Netherlands">Netherlands</option>
				<option value="Netherlands Antilles">Netherlands Antilles</option>
				<option value="New Caledonia">New Caledonia</option>
				<option value="New Zealand">New Zealand</option>
				<option value="Nicaragua">Nicaragua</option>
				<option value="Niger">Niger</option>
				<option value="Nigeria">Nigeria</option>
				<option value="Norfolk Island">Norfolk Island</option>
				<option value="Northern Mariana Islands">Northern Mariana Islands</option>
				<option value="Norway">Norway</option>
				<option value="Occupied Palestinian Territory">Occupied Palestinian Territory</option>
				<option value="Oman">Oman</option>
				<option value="Pakistan">Pakistan</option>
				<option value="Palau">Palau</option>
				<option value="Panama">Panama</option>
				<option value="Papua New Guinea">Papua New Guinea</option>
				<option value="Paraguay">Paraguay</option>
				<option value="Peru">Peru</option>
				<option value="Philippines">Philippines</option>
				<option value="Pitcairn">Pitcairn</option>
				<option value="Poland">Poland</option>
				<option value="Portugal">Portugal</option>
				<option value="Puerto Rico">Puerto Rico</option>
				<option value="Qatar">Qatar</option>
				<option value="R�union">R�union</option>
				<option value="Romania">Romania</option>
				<option value="Russian Federation">Russian Federation</option>
				<option value="Rwanda">Rwanda</option>
				<option value="Saint-Barth�lemy">Saint-Barth�lemy</option>
				<option value="Saint Helena">Saint Helena</option>
				<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
				<option value="Saint Lucia">Saint Lucia</option>
				<option value="Saint-Martin (French part)">Saint-Martin (French part)</option>
				<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
				<option value="Saint Vincent/Grenadines">Saint Vincent/Grenadines</option>
				<option value="Samoa">Samoa</option>
				<option value="San Marino">San Marino</option>
				<option value="Sao Tome and Principe">Sao Tome and Principe</option>
				<option value="Saudi Arabia">Saudi Arabia</option>
				<option value="Senegal">Senegal</option>
				<option value="Serbia">Serbia</option>
				<option value="Seychelles">Seychelles</option>
				<option value="Sierra Leone">Sierra Leone</option>
				<option value="Singapore">Singapore</option>
				<option value="Slovakia">Slovenia</option>
				<option value="Solomon Islands">Solomon Islands</option>
				<option value="Somalia">Somalia</option>
				<option value="South Africa">South Africa</option>
				<option value="South Korea">South Korea</option>
				<option value="Spain">Spain</option>
				<option value="Sri Lanka">Sri Lanka</option>
				<option value="Sudan">Sudan</option>
				<option value="Suriname">Suriname</option>
				<option value="Svalbard/Jan Mayen Islands">Svalbard/Jan Mayen Islands</option>
				<option value="Swaziland">Swaziland</option>
				<option value="Sweden">Sweden</option>
				<option value="Switzerland">Switzerland</option>
				<option value="Syrian Arab Republic">Syrian Arab Republic</option>
				<option value="Tajikistan">Tajikistan</option>
				<option value="Thailand">Thailand</option>
				<option value="Yugoslav Republic of Macedonia">Yugoslav Republic of Macedonia</option>
				<option value="Togo">Togo</option>
				<option value="Tokelau">Tokelau</option>
				<option value="Tonga">Tonga</option>
				<option value="Trinidad/Tobago">Trinidad/Tobago</option>
				<option value="Tunisia">Tunisia</option>
				<option value="Turkey">Turkey</option>
				<option value="Turkmenistan">Turkmenistan</option>
				<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
				<option value="Tuvalu">Tuvalu</option>
				<option value="Uganda">Uganda</option>
				<option value="Ukraine">Ukraine</option>
				<option value="United Arab Emirates">United Arab Emirates</option>
				<option value="United Kingdom">United Kingdom</option>
				<option value="United Republic of Tanzania">United Republic of Tanzania</option>
				<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
				<option value="Uruguay">Uruguay</option>
				<option value="Uzbekistan">Uzbekistan</option>
				<option value="Vanuatu">Vanuatu</option>
				<option value="Venezuela">Venezuela</option>
				<option value="Viet Nam">Viet Nam</option>
				<option value="Wallis/Futuna Islands">Wallis/Futuna Islands</option>
				<option value="Western Sahara">Western Sahara</option>
				<option value="Yemen">Yemen</option>
				<option value="Zambia">Zambia</option>	
              </select><span class="notice"><?php echo $country_error; ?></span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">How did you find out about AAD?<strong>*</strong></span></td>
              </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><table width="317" border="0" cellspacing="0" cellpadding="4">
                <tr valign="bottom">
                  <td><div align="right">
					<input name="AboutAAD" type="radio" value="Media">
                                      </div></td>
                  <td class="style2">Media (TV/newspaper/magazine)</td>
                </tr>
                <tr valign="bottom">
                  <td><div align="right">
                      <input name="AboutAAD" type="radio" value="FriendFamily">
                  </div></td>
                  <td class="style2">Friend/Family</td>
                </tr>
                <tr valign="bottom">
                  <td><div align="right">
                      <input name="AboutAAD" type="radio" value="MedicalProfessional">
                  </div></td>
                  <td class="style2">Medical Professional (Doctor/Therapist)</td>
                </tr>
                <tr valign="bottom">
                  <td><div align="right">
                      <input name="AboutAAD" type="radio" value="Internet">
                  </div></td>
                  <td class="style2">Internet</td>
                </tr>
                <tr valign="bottom">
                  <td><div align="right">
                      <input name="AboutAAD" type="radio" value="InsuranceCompany">
                  </div></td>
                  <td class="style2">Insurance Company</td>
                </tr>
                <tr valign="bottom">
                  <td><div align="right">
                      <input name="AboutAAD" type="radio" value="Other">
                  </div></td>
                  <td class="style2">Other (Please list):</td>
                </tr>
                <tr valign="bottom">
                  <td>&nbsp;</td>
                  <td class="style2"><textarea name="PleaseList" id="PleaseList"></textarea></td>
                </tr>
                <tr valign="bottom">
                  <td colspan="2"><span class="notice"><?php echo $about_AAD_error; ?></span></td>
                </tr>                
              </table></td>
              </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">Please Describe Your Amputation Level/Level of Deficiency: <br>
                </span>
                    <textarea name="AmputationLeve" id="AmputationLeve"></textarea>
                  
                  <span class="style2"> </span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">Please Describe Your Current Prostheses:<br>
                </span>
                    <textarea name="CurrentProsthesis" id="CurrentProsthesis"></textarea>
                  
                  <span class="style2"> </span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2">&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">What Types of Prosthesis are You Interested in Receiving (you may choose more than one)?<strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</strong></span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><table width="317" border="0" cellspacing="0" cellpadding="4">
                  <tr valign="bottom">
                    <td>
                        <div align="right">
                          <input name="TypesOfProsthesis" type="radio" value="Passive/Cosmetic">
                        </div>                    </td>
                    <td class="style2">Passive/Cosmetic</td>
                  </tr>
                  <tr valign="bottom">
                    <td>
                        <div align="right">
                          <input name="TypesOfProsthesis" type="radio" value="Body-Powered">
                        </div>                    </td>
                    <td class="style2">Body-Powered</td>
                  </tr>
                  <tr valign="bottom">
                    <td>
                        <div align="right">
                          <input name="TypesOfProsthesis" type="radio" value="Electrically-Powered/Myoelectric">
                        </div>                    </td>
                    <td class="style2">Electrically-Powered/Myoelectric</td>
                  </tr>
                  <tr valign="bottom">
                    <td>
                        <div align="right">
                          <input name="TypesOfProsthesis" type="radio" value="Hybrid">
                        </div>                    </td>
                    <td class="style2">Hybrid</td>
                  </tr>
                  <tr valign="bottom">
                    <td>
                        <div align="right">
                          <input name="TypesOfProsthesis" type="radio" value="Activity-Specific">
                        </div>                    </td>
                    <td class="style2">Activity-Specific</td>
                  </tr>
                  <tr valign="bottom">
                    <td>
                        <div align="right">
                          <input name="TypesOfProsthesis" type="radio" value="Unsure">
                        </div>                    </td>
                    <td class="style2">Unsure</td>
                  </tr>
              </table>		</td>
	</tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">Please Describe Your Request:</span><br>
                    <textarea name="RequestDescription" id="RequestDescription"></textarea>                </td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">How Would You Like Us to Respond to Your Request? </span></td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td colspan="2">
			  
				<table border="0" cellspacing="0" cellpadding="4">
                  <tr valign="bottom">
                    <td width="21"><div align="right">
                        <input name="RespondToRequest" type="radio" value="E-Mail">
                    </div></td>
                    <td class="style2">E-Mail</td>
                  </tr>
                  <tr>
                    <td ><div align="right">
                        <input name="RespondToRequest" type="radio" value="Phone">
                    </div></td>
                    <td class="style2">Phone</td>
                  </tr>
                  <tr>
                    <td><div align="right">
                        <input name="RespondToRequest" type="radio" value="Mail">
                    </div></td>
                    <td class="style2">Mail</td>
                  </tr>
                </table>
            <tr>
              <td valign="top">&nbsp;</td>
              <td colspan="2">            
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><span class="style2">Additional Comments: </span>            
            <tr>
              <td>&nbsp;</td>
              <td colspan="2"><textarea name="AdditionalComments" id="AdditionalComments"></textarea>            
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>
                  <input type="submit" name="Submit" value="Submit">              </td>
              <td>&nbsp;</td>
            </tr>
		</table>
</form>

          </td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        </tr>
    </table>
    <!-- InstanceEndEditable --> </td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="javascript:;" onMouseOver="MM_swapImage('nav_01about','','images/nav_01about_ov.gif',1);MM_showMenu(window.mm_menu_0519153527_0,150,0,null,'nav_01about')" onMouseOut="MM_swapImgRestore();MM_startTimeout()"></a><a href="about.html" onMouseOver="MM_swapImage('nav_01about','','images/nav_01about_ov.gif',1);MM_showMenu(window.mm_menu_0519153527_0,150,0,null,'nav_01about')" onMouseOut="MM_swapImgRestore();MM_startTimeout();"><img name="nav_01about" src="images/nav_01about.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="newDevelop.html" onMouseOver="MM_swapImage('nav_02new','','images/nav_02new_ov.gif',1)" onMouseOut="MM_swapImgRestore()"><img name="nav_02new" src="images/nav_02new.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="center.html" onMouseOver="MM_swapImage('nav_03center','','images/nav_03center_ov.gif',1);MM_showMenu(window.mm_menu_0519154441_0,150,0,null,'nav_03center')" onMouseOut="MM_swapImgRestore();MM_startTimeout();"><img name="nav_03center" src="images/nav_03center.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="news.html" onMouseOver="MM_swapImage('nav_04newsroom','','images/nav_04newsroom_ov.gif',1);MM_showMenu(window.mm_menu_0519154704_0,150,0,null,'nav_04newsroom')" onMouseOut="MM_swapImgRestore();MM_startTimeout()"><img name="nav_04newsroom" src="images/nav_04newsroom.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="contactUs.html" onMouseOver="MM_swapImage('nav_05contact','','images/nav_05contact_ov.gif',1)" onMouseOut="MM_swapImgRestore()"><img name="nav_05contact" src="images/nav_05contact.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="sitemap.html" onMouseOver="MM_swapImage('nav_06sitemap','','images/nav_06sitemap_ov.gif',1)" onMouseOut="MM_swapImgRestore()"><img name="nav_06sitemap" src="images/nav_06sitemap.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><img name="nav_07search" src="images/nav_07search.gif" width="149" height="36" border="0" alt=""></td>
  </tr>
  <tr>
    <td valign="top" bgcolor="A6489A">&nbsp;</td>
    <td colspan="2" valign="top" bgcolor="A6489A">
	<!--siteLevel Search Begin-->
	<form method="get" action="http://sitelevel.whatuseek.com/query.go" TARGET="_self">
		<table border="0" cellspacing="0" cellpadding="0">
			<tr>
				<td width="100%">
					<table cellspacing=0 cellpadding=0 border=0>
						<tr>
							<td align="center" valign="middle" nowrap>
								<input type="hidden" name="crid" value="6a967b3b36d90a43">
 								<input type="text" NAME="query" SIZE="10" VALUE MAXLENGTH="100">
							</td>
							<td valign="middle" align="right">
								&nbsp;<INPUT TYPE="image" SRC="images/go_button.gif" HEIGHT="17" WIDTH="24" BORDER="0" ALT="Go" name="B1" value="Search" align="absmiddle">
							</td>
						</tr>
					</table>
				</td>
			</tr>
		</table>
	</form>
<img src="http://sitelevel.whatuseek.com/htmlbox.go?crid=6a967b3b36d90a43" width=1 height=1>	
	<!--siteLevel Search End-->
	<!--<form name="form1" method="get" action="search.php">
      <input name="SearchString" type="text" id="SearchString" size="10">
      <img src="../images/go_button.gif" name="Go" width="24" height="17" hspace="0" vspace="0" align="absmiddle" id="Go">
    </form>-->
	</td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><img name="nav_07_c" src="images/nav_07_c.gif" width="149" height="19" border="0" alt=""></td>
  </tr>
  <tr>
    <td colspan="3" valign="top"><a href="http://www.armdynamics.com/spanish/"><img name="nav_08en" src="images/nav_08en.gif" width="149" height="30" border="0" alt=""></a></td>
  </tr>
  <tr>
    <td colspan="3" valign="top" bgcolor="#000000"><!-- InstanceBeginEditable name="1" -->
      <p>gion4</p>
      <table width="100" border="0" align="center" cellpadding="0" cellspacing="0">
        <tr>
          <td><p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p>
          <p>&nbsp;</p></td>
        </tr>
      </table>
    <!-- InstanceEndEditable --></td>
  </tr>
</table>
<table width="722" border="0" align="center" cellpadding="5" cellspacing="0">
  <tr>
    <td width="770" class="style2"><div align="center" class="style3"><!-- InstanceBeginEditable name="tagline" --><img src="images/lifeWithin.gif" width="145" height="16"><!-- InstanceEndEditable -->
      <p>Copyright &copy; 2006 Advanced Arm Dynamics, Inc. All Rights Reserved. <br>
          <a href="index.html">Home</a>| <a href="about.html">About Us</a>| <a href="newDevelop.html">New Developments</a> | <a href="center.html">Centers of Excellence</a> | <a href="news.html">Newsroom</a> | <a href="contactUs.html">Contact Us</a> | <a href="sitemap.html">Site Map</a>| <a href="privacy.html">Privacy Practices</a> </p>
    </div></td>
  </tr>
</table>
<script src="http://www.google-analytics.com/urchin.js" type="text/javascript">
</script>
<script type="text/javascript">
_uacct = "UA-543081-1";
urchinTracker();
</script></body>
<!-- InstanceEnd --></html>