ÿþ <form id="emf-form" target="_blank" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/04XlcQg586efS11" name="emf-form"> <table style="text-align:left;" cellpadding="2" cellspacing="0" border="0" bgcolor="transparent"> <tr> <td style="" colspan="2"> <font face="Verdana" size="2" color="#000000"><b style="font-size:20px;">Request for support.</b><br /> <label style="font-size:15px;">Computer broken? Too slow? Virus or malware? or just need a little help. Then fill in the following form.<br /></label><br /></font> </td> </tr> <tr valign="top"> <td id="td_element_label_0" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Name</b></font> <span style="color:red;"><small>*</small></span> </td> <td id="td_element_field_0" style=""> <input id="element_0" name="element_0" value="" size="30" class="validate[required]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_1" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Email</b></font> <span style="color:red;"><small>*</small></span> </td> <td id="td_element_field_1" style=""> <input id="element_1" name="element_1" class="validate[required,custom[email]]" value="" size="30" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_2" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Address</b></font> </td> <td id="td_element_field_2" style=""> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_3" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Street Address</b></font> </td> <td id="td_element_field_3" style=""> <input id="element_3" name="element_3" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_4" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Address Line 2</b></font> </td> <td id="td_element_field_4" style=""> <input id="element_4" name="element_4" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_5" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>City</b></font> </td> <td id="td_element_field_5" style=""> <input id="element_5" name="element_5" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_6" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>State / Province / Region</b></font> </td> <td id="td_element_field_6" style=""> <input id="element_6" name="element_6" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_7" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Postal / Zip Code</b></font> </td> <td id="td_element_field_7" style=""> <input id="element_7" name="element_7" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_8" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Country</b></font> </td> <td id="td_element_field_8" style=""> <input id="element_8" name="element_8" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_9" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Phone</b></font> <span style="color:red;"><small>*</small></span> </td> <td id="td_element_field_9" style=""> <input id="element_9" name="element_9" class="validate[required,custom[telephone]]" value="" size="30" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_10" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Subject</b></font> <span style="color:red;"><small>*</small></span> </td> <td id="td_element_field_10" style=""> <input id="element_10" name="element_10" value="" size="30" class="validate[required]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_11" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Please select from the following choices:-</b></font> </td> <td id="td_element_field_11" style=""> <div style="float:left;width:50%;padding-bottom:5px;"> <input id="element_11_0" name="element_11" value="Hardware problem" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Hardware problem&nbsp;</font> </div> <div style="float:left;width:50%;padding-bottom:5px;"> <input id="element_11_1" name="element_11" value="Software Problem" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Software Problem&nbsp;</font> </div> <div style="float:left;width:50%;padding-bottom:5px;"> <input id="element_11_2" name="element_11" value="Virus infection" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Virus infection&nbsp;</font> </div> <div style="float:left;width:50%;padding-bottom:5px;"> <input id="element_11_3" name="element_11" value="Network issues" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Network issues&nbsp;</font> </div> <div style="float:left;width:50%;padding-bottom:5px;"> <input id="element_11_4" name="element_11" value="Slow computer" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Slow computer&nbsp;</font> </div> <div style="float:left;width:50%;padding-bottom:5px;"> <input id="element_11_5" name="element_11" value="Other, Please explain below." class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Other, Please explain below.&nbsp;</font> </div> <div style="clear:both;"></div> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_12" style="" align="left"> <font face="Verdana" size="2" color="#000000"><b>Message</b></font> <span style="color:red;"><small>*</small></span> </td> <td id="td_element_field_12" style=""> <textarea id="element_12" name="element_12" cols="60" rows="10" class="validate[required]"> </textarea> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr> <td colspan="2"> <script type="text/javascript"> //<![CDATA[ var RecaptchaOptions = { theme: 'clean', custom_theme_widget: 'emf-recaptcha_widget' }; //]]> </script> <script type="text/javascript" src="https://www.google.com/recaptcha/api/challenge?k=6LchicQSAAAAAGksQmNaDZMw3aQITPqZEsX77lT9"> </script> <noscript><iframe src="https://www.google.com/recaptcha/api/noscript?k=6LchicQSAAAAAGksQmNaDZMw3aQITPqZEsX77lT9" height="300" width="500" frameborder="0"></iframe><br /> <textarea name="recaptcha_challenge_field" rows="3" cols="40"> </textarea> <input type="hidden" name="recaptcha_response_field" value="manual_challenge" /></noscript> </td> </tr> <tr> <td colspan="2" align="left"> <input name="element_counts" value="13" type="hidden" /> <input name="embed" value="forms" type="hidden" /><input value="Submit" type="submit" /><input value="Clear" type="reset" /> </td> </tr>