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<script type="text/javascript" src="formcheck.js"> </script>



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<body>

<form id="registration" method="post" action="mail.php">

		<table cellpadding="5" cellspacing="5" border="0" width="600">

			<tbody><tr>

				<td>

					<p class="rg_heading">Register Your Product<br></p><span>Please fill out the following form to register your warranty and press<br> the "Submit" button when complete.</span>

				</td>

			</tr>

			<tr>

				<td>

					<p class="brdcrumb txthding">Customer Information</p>

				</td>

			</tr>

			<tr>

				<td>

					<table width="95%" cellpadding="0" cellspacing="0">

						<tbody><tr>

							<td width="19%">

								<strong> Salution</strong><br><input type="text" size="8" name="salution" id="salution">

							</td>

 							<td width="27%">

								<strong>*First Name</strong><br><input type="text" size="15" name="fname" id="fname" style="margin: 0px 4px;" class="validate['required']">

							</td>

 							<td width="54%">

								<strong>*Last Name</strong><br><input type="text" size="15" name="lname" id="lname" class="validate['required']">

							</td>

						</tr>

					</tbody></table>

				</td>

			</tr>

			<tr>

				<td style="padding-top:20px;">

					<strong>*Address 1</strong><br><input type="text" size="50" id="address1" name="address1" class="validate['required']">

				</td>

			</tr>

			<tr>

				<td>

					 <strong> Address 2</strong><br><input type="text" size="50" id="address2" name="address2">

				</td>

			</tr>

			<tr>

				<td>

					<table width="70%" cellpadding="0" cellspacing="0">

						<tbody><tr>

							<td>

								<strong>*City</strong><br><input type="text" size="20" name="city" id="city" value="" class="validate['required']">

							</td>

 							<td>

								<strong>*State</strong><br>

																<select style="width:128px; margin: 0px 4px" name="state" id="state" class="validate['required']">				

									<option value="">-Select-</option>

									<option value="" class="cnamebold">--United States--</option>									<option value="Alabama">Alabama</option>

																		<option value="Alaska">Alaska</option>

																		<option value="Arizona">Arizona</option>

																		<option value="Arkansas">Arkansas</option>

																		<option value="California">California</option>

																		<option value="Colorado">Colorado</option>

																		<option value="Connecticut">Connecticut</option>

																		<option value="Delaware">Delaware</option>

																		<option value="District Of Columbia">District Of Columbia</option>

																		<option value="Florida">Florida</option>

																		<option value="Georgia">Georgia</option>

																		<option value="Hawaii">Hawaii</option>

																		<option value="Idaho">Idaho</option>

																		<option value="Illinois">Illinois</option>

																		<option value="Indiana">Indiana</option>

																		<option value="Iowa">Iowa</option>

																		<option value="Kansas">Kansas</option>

																		<option value="Kentucky">Kentucky</option>

																		<option value="Louisiana">Louisiana</option>

																		<option value="Maine">Maine</option>

																		<option value="Maryland">Maryland</option>

																		<option value="Massachusetts">Massachusetts</option>

																		<option value="Michigan">Michigan</option>

																		<option value="Minnesota">Minnesota</option>

																		<option value="Mississippi">Mississippi</option>

																		<option value="Missouri">Missouri</option>

																		<option value="Montana">Montana</option>

																		<option value="Nebraska">Nebraska</option>

																		<option value="Nevada">Nevada</option>

																		<option value="New Hampshire">New Hampshire</option>

																		<option value="New Jersey">New Jersey</option>

																		<option value="New Mexico">New Mexico</option>

																		<option value="New York">New York</option>

																		<option value="North Carolina">North Carolina</option>

																		<option value="North Dakota">North Dakota</option>

																		<option value="Ohio">Ohio</option>

																		<option value="Oklahoma">Oklahoma</option>

																		<option value="Oregon">Oregon</option>

																		<option value="Pennsylvania">Pennsylvania</option>

																		<option value="Rhode Island">Rhode Island</option>

																		<option value="South Carolina">South Carolina</option>

																		<option value="South Dakota">South Dakota</option>

																		<option value="Tennessee">Tennessee</option>

																		<option value="Texas">Texas</option>

																		<option value="Utah">Utah</option>

																		<option value="Vermont">Vermont</option>

																		<option value="Virginia">Virginia</option>

																		<option value="Washington">Washington</option>

																		<option value="West Virginia">West Virginia</option>

																		<option value="Wisconsin">Wisconsin</option>

																		<option value="Wyoming">Wyoming</option>

									<option value="" class="cnamebold">--Canada--</option>									<option value="Alberta">Alberta</option>

																		<option value="British Columbia">British Columbia</option>

																		<option value="Manitoba">Manitoba</option>

																		<option value="New Brunswick">New Brunswick</option>

																		<option value="Newfoundland and Labrador">Newfoundland and Labrador</option>

																		<option value="Northwest Territories">Northwest Territories</option>

																		<option value="Nova Scotia">Nova Scotia</option>

																		<option value="Nunavut">Nunavut</option>

																		<option value="Ontario">Ontario</option>

																		<option value="Prince Edward Island">Prince Edward Island</option>

																		<option value="Quebec">Quebec</option>

																		<option value="Saskatchewan">Saskatchewan</option>

																		<option value="Yukon">Yukon</option>

																	</select>

							</td>

 							<td>

																<strong>Zip</strong><br><input type="text" size="15" name="zip" id="zip">

							</td>

						</tr>

					</tbody></table>

				</td>

			</tr>

			<tr>

				<td>&nbsp;</td>

			</tr>			

			<tr>

				<td>

					<table width="100%" cellpadding="0" cellspacing="0">

						<tbody><tr>

							<td width="44%">

								<strong>*Primary phone</strong>(000 000-0000)<br><input type="text" size="20" name="pphone" id="pphone" class="validate['required','phone']" maxlength="12">

							</td>

 							<td width="50%">

								<strong>Secondary phone</strong>(000 000-0000)<br><input type="text" size="20" name="sphone" id="sphone"  maxlength="12" class="validate['phone']">

							</td> 

 							<td width="3%">&nbsp;

								

							</td> 

 							<td width="3%">&nbsp;

								

							</td> 

						</tr>
						  <tr>
						    <td>&nbsp;</td>
						    <td>&nbsp;</td>
						    <td>&nbsp;</td>
						    <td>&nbsp;</td>
					      </tr>

				      </tbody>
					</table> 

				</td>

			</tr>

			<tr>

				<td>

					<strong>*Email</strong><br><input type="text" size="40" name="email" id="email" class="validate['required','email']">

				</td>

			</tr>

			<tr>

				<td>&nbsp;

					

				</td>

			</tr>

			<tr>

				<td>

					<p class="brdcrumb txthding">Fabrictech Product Information</p>

				</td>

			</tr>

			<tr>

				<td>

					<table width="100%" cellpadding="0" cellspacing="0">

						<tbody><tr>

							<td width="22%">

								<strong>*Product Name</strong><br><input type="text" size="10" name="pname" id="pname" class="validate['required']">

							</td>

 							<td width="11%">

								<strong>*Size</strong><br><input type="text" size="5" name="size" id="size" class="validate['required']">

							</td> 

 							<td width="36%">

								<strong>*Date of Purchase</strong>(mm/dd/yyyy)<br><input type="text" size="25" name="dop" id="dop" class="validate['required']" maxlength="10" style="width:180px">

							</td> 

 							<td width="31%">

								<strong>Retail Price</strong><br>$<input type="text" size="8" name="rprice" id="rprice">

							</td> 

						</tr>

					</tbody></table> 					 

				</td>

			</tr>

			<tr>

				<td>

					<strong>Primary Reason for purchase of the product</strong><br><input type="text" size="43" name="reason" id="reason">

				</td>

			</tr>

			<tr>

				<td>&nbsp;

					

				</td>

			</tr>

			<tr>

				<td>

					<strong>Store Name</strong><br><input type="text" size="30" name="sname" id="sname">

				</td>

			</tr>

			<tr>

				<td>

					<strong>Store Location</strong>(City, State) *Note: If Purchased online, please use website address<br><input type="text" size="50" name="slocation" id="slocation">

				</td>

			</tr>

			<tr>

				<td>&nbsp;

					

				</td>

			</tr>

			<tr>

				<td>

					<p class="brdcrumb txthding2">If Purchased With A New Mattress at a Retailer,<br> Please Input the Information Below</p>

				</td>

			</tr>

			<tr>

				<td>

					<table width="80%" cellpadding="0" cellspacing="0">

						<tbody><tr>

							<td>

								<strong>Mattress Manufacturer<strong><br><input type="text" size="30" name="manufact" id="manufact">

							</strong></strong></td>

 							<td>

								<strong>Mattress Model Name <strong><br><input type="text" size="30" name="model" id="model">

							</strong></strong></td> 

 							<td>&nbsp;

								

							</td>  

						</tr>

					</tbody></table> 					 

					 

				</td>

			</tr>

			<tr>

				<td>

					<table width="80%" cellpadding="0" cellspacing="0">

						<tbody><tr>

							<td>

								<strong>Invoice Number<strong><br><input type="text" size="30" name="invoice" id="invoice">

							</strong></strong></td>

 							<td>

								<strong>Mattress Retail Price<strong><br><input type="text" size="30" name="mprice" id="mprice">

							</strong></strong></td> 

 							<td>&nbsp;

								

							</td>  

						</tr>

					</tbody></table> 

				</td>

			</tr>

			<tr>

				<td>

					<strong>Customer Comments<strong><br><textarea class="address1" id="comment" name="comment" rows="5" cols="40"></textarea>

				</strong></strong></td>

			</tr>

			<tr>

				<td>

					<p><strong>Fields marked with an * are mandatory.</strong></p>

				</td>

			</tr>

			<tr>

				<td>

					<input type="submit" value="Submit" name="submit">

			  </td>

			</tr>

    </tbody></table>

</form>

</body>

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