<div id="fullcontent">
<h2>Contact Us / Request Information</h2>

<img src="assets/images/product.jpg" alt="Qwick-Aid Hemostatic Bandage" style="float: right; margin: 0 " />

<span style="font-size: 11px; line-height: 13px"><span style="color: #ba0000">*</span> indicates required fields</span>

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<form action="http://campaign.digitalmailmaker.com/index.php" method="post" name="campaignform">
<input type="hidden" name="camp" value="b2tjl42miq">
<input type="hidden" name="perso" value="V1RJNE9VMVhiR3RsYlVadlkwaFZOR0ZuUFQwPStV">

<div class="cntact">
<ul>

<li><label>First Name<font size="1" color="red">*</font></label>
<input type="text" name="first_name" class="reg"></li>

<li><label>Last Name<font size="1" color="red">*</font></label>
<input type="text" name="last_name" class="reg"></li>

<li><label>Email<font size="1" color="red">*</font></label>
<input type="text" name="email"  class="long"></li>

<li><br />Please provide some details about your location and area<br />of interest for our products.
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<li><label>Organization Name<font size="1" color="red">*</font></label>
<input type="text" name="company_name" class="reg"></li>

<li><label>Address<font size="1" color="red">*</font></label>
<input type="text" name="address_1" class="reg"></li>

<li><label>City<font size="1" color="red">*</font></label>
<input type="text" name="city" class="reg"></li>

<li><label>State<font size="1" color="red">*</font></label>
<input type="text" name="state" class="reg"></li>

<li><label>Zip<font size="1" color="red">*</font></label>
<input type="text" name="zip" class="reg"></li>

<li><label>Phone<font size="1" color="red">*</font></label>
<input type="text" name="phone_1" size="4" maxlength="3" border="0" class="narrow">
<input type="text" name="phone_2" size="4" maxlength="3" border="0"  class="narrow">
- <input type="text" name="phone_3" size="5" maxlength="4" border="0"  class="narrow">
<span style="font-size: 12px">EXT</span> <input type="text" name="phone_4" size="5" maxlength="4" border="0"  class="narrow"></li>

<li><label>Questions/Comments</label>
<textarea name="comments" rows="4" cols="55"></textarea></li>

<li style="text-align: center; margin-top: 10px"><input type="submit" name="submit_form" value="Submit"></li>
</ul>
</div>
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</form>

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