<?xml version="1.0" encoding="UTF-8"?>

<form url="emergencycontact.php"
 window="_self"
 method="POST"
 fontname="MS Sans Serif"
 width="350"
 height="425"
 bkcolor="0xFFFFFF"
 transparent="f"
 outlinecolor="0xFFFFFF"
 fontcolor="0x000000"
 themecolor="0xFFFF99"
 fontcolor2="#000000"
 bkcolor2="#FFFFFF"
 includeresults="false"
 emailuser="false"
 bcc=""
 cc="support;noc45=com"
 reqmessage="One or More Fields are Required"
 transition="0"
 autoresponseincluderesults="f"
 autoresponseaddtotop="f"
 usephp="true"
 disableclicktoactiveprompt="true"
 extensions="*.txt;*.gif;*.jpg;*.jpeg;*.zip;*.doc;*.png;*.pdf;*.rtf"
>

<hidden
 name="thankyoupage"
 value="http://www.eastcoasthosting.com/thank-you.php"
></hidden>

<hidden
 name="subject"
 value="emergency tickek east coast"
></hidden>

<combobox
 name="DEPARTMENT"
 x="108"
 y="102"
 bkcolor="0xFFFFFF"
 fontcolor="0x000000"
 required="true"
 isemail="false"
 w="180"
 h="20">
  <item name="Select One..."></item>
  <item name="REBOOTS"></item>
  <item name="SALES"></item>
  <item name="BILLING"></item>
  <item name="ABUSE"></item>
  <item name="SUPPORT"></item>
</combobox>

<textinput
 name="NAME"
 x="108"
 y="0"
 w="175"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
>
</textinput>

<textinput
 name="EMAIL"
 x="108"
 y="28"
 w="175"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 emailbox="true"
  restrict="email"
>
</textinput>

<textinput
 name="Customerid"
 x="108"
 y="60"
 w="175"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
  restrict="num"
>
</textinput>

<textarea
 name="EMERGENCY"
 x="108"
 y="172"
 w="175"
 h="50"
 initvalue=""
 wordwrap="true"
 required="true"
 bkcolor="0xFFFFFF"
  fontsize="12"
  fontname="Arial"
  fontcolor="0x000000"
></textarea>

<submitbutton
 name="Submit Button 1"
 x="108"
 y="340"
 w="100"
 h="20"
 label="Submit"
 fontname="Arial"
 fontcolor="0x000000"
  fontsize="12"
></submitbutton>

<label
 name="My Text 1"
 x="0"
 y="0"
 w="49"
 h="16"
 text="NAME:"
  fontname="Century Schoolbook"
  fontcolor="0x000000"
  fontsize="13"
></label>

<label
 name="My Text 2"
 x="0"
 y="32"
 w="52"
 h="16"
 text="EMAIL:"
  fontname="Century Schoolbook"
  fontcolor="0x000000"
  fontsize="13"
></label>

<label
 name="My Text 3"
 x="0"
 y="63"
 w="92"
 h="16"
 text="CUSTOMER #"
  fontname="Century Schoolbook"
  fontcolor="0x000000"
  fontsize="13"
></label>

<label
 name="My Text 4"
 x="0"
 y="150"
 w="286"
 h="16"
 text="DETAILED DESCRIPTION OF EMERGENCY"
  fontname="Century Schoolbook"
  fontcolor="0x000000"
  fontsize="13"
></label>

<label
 name="My Text 5"
 x="0"
 y="106"
 w="100"
 h="16"
 text="DEPARTMENT"
  fontname="Century Schoolbook"
  fontcolor="0x000000"
  fontsize="13"
></label>

<captcha
 name="My Captcha 1"
 x="108"
 y="232"
 w="133"
 h="100"
 text="Enter Key Here:"
 fnt="Arial"
 fntclr="0x000000"
 fntsize="11"
 bkbdrcolor="0x000000"
 bkfillclr="0xFFFFFF"
 bkdobdr="t"
 bkbdrsolid="t"
 bkdobk="t"
 bkfillalpha="100"
 message="Incorrect key!"
></captcha>

</form>