document.write('<style type="text/css">');
document.write('');
document.write('</style>');

document.write('<table>');
document.write('<form action="http://service.clearservice.com:80/rmg/webforms/processform.jsp" onsubmit="return validate()" name="MainForm">');
document.write('<input type="hidden" name="WebformID" value="3">');
document.write('<input type="hidden" name="ServiceQueueID" value="8">');
document.write('<tr><td class="intro" style="font-family:Default; color:Black; font-size:12" colspan="2"></td></tr>');

    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">First Name *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="FirstName"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Last Name *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="LastName"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Company Name *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="CompanyName"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Phone Number *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="BusinessPhone"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Street Address *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="StreetAddress"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">City *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="City"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">State/Province *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="Province"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Country *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="Country"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Postal Code *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="PostalCode"></td></tr>');
    
    document.write('<tr><td style="font-family:Default; color:blue; font-size:12">Email Address *</td><td><input style="font-family:Default; color:Black; font-size:12" type="text" size="30" name="EMailAddress"></td></tr>');
    
   document.write('\n');
    document.write('');
   
   document.write('\n');
   document.write('');
   
    document.write('<input type="hidden" name="QuestionMax" value="0">');
    
    document.write('<tr><td style="font-family:Default; color:Black; font-size:12" colspan="2">Please check all categories that apply.</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup1" ></td><td style="font-family:Default; color:blue; font-size:12">Begin FREE Trial of Two Issues of SCAN/DCR</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup2" ></td><td style="font-family:Default; color:blue; font-size:12">Purchase an Annual Subscription. Have someone call for Credit Card.</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup3" ></td><td style="font-family:Default; color:blue; font-size:12">Vendor</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup4" ></td><td style="font-family:Default; color:blue; font-size:12">Value-Added Reseller</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup5" ></td><td style="font-family:Default; color:blue; font-size:12">Systems Integrator</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup6" ></td><td style="font-family:Default; color:blue; font-size:12">End-User</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup7" ></td><td style="font-family:Default; color:blue; font-size:12">Heard about SCAN/DCR through AIM</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup8" ></td><td style="font-family:Default; color:blue; font-size:12">Heard about SCAN/DCR through RFID World</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup9" ></td><td style="font-family:Default; color:blue; font-size:12">Heard about SCAN/DCR through RFID Journal Live</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup10" ></td><td style="font-family:Default; color:blue; font-size:12">Heard about SCAN/DCR from High-Tech Aid</td></tr>');
    
    document.write('<tr><td><input class="checkbox" type="checkbox" name="MarketingGroup11" ></td><td style="font-family:Default; color:blue; font-size:12">Heard about SCAN/DCR from a Collegue</td></tr>');
    
document.write('<tr><td align="center" colspan="2"><input style="font-family:Default; color:Black; font-size:12" type="submit" name="Submit" value="Submit"></td></tr>');
document.write('</form>');
document.write('</table>');

<!-- now write the javascript to validate the required fields -->
function validate(){

if(document.MainForm.FirstName.type!="select-one" && document.MainForm.FirstName.value==""){
   // alert(document.MainForm.FirstName.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.FirstName.type!="'select-one" && document.MainForm.FirstName.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.LastName.type!="select-one" && document.MainForm.LastName.value==""){
   // alert(document.MainForm.LastName.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.LastName.type!="'select-one" && document.MainForm.LastName.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.CompanyName.type!="select-one" && document.MainForm.CompanyName.value==""){
   // alert(document.MainForm.CompanyName.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.CompanyName.type!="'select-one" && document.MainForm.CompanyName.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.BusinessPhone.type!="select-one" && document.MainForm.BusinessPhone.value==""){
   // alert(document.MainForm.BusinessPhone.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.BusinessPhone.type!="'select-one" && document.MainForm.BusinessPhone.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.StreetAddress.type!="select-one" && document.MainForm.StreetAddress.value==""){
   // alert(document.MainForm.StreetAddress.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.StreetAddress.type!="'select-one" && document.MainForm.StreetAddress.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.City.type!="select-one" && document.MainForm.City.value==""){
   // alert(document.MainForm.City.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.City.type!="'select-one" && document.MainForm.City.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.Province.type!="select-one" && document.MainForm.Province.value==""){
   // alert(document.MainForm.Province.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.Province.type!="'select-one" && document.MainForm.Province.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.Country.type!="select-one" && document.MainForm.Country.value==""){
   // alert(document.MainForm.Country.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.Country.type!="'select-one" && document.MainForm.Country.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.PostalCode.type!="select-one" && document.MainForm.PostalCode.value==""){
   // alert(document.MainForm.PostalCode.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.PostalCode.type!="'select-one" && document.MainForm.PostalCode.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

if(document.MainForm.EMailAddress.type!="select-one" && document.MainForm.EMailAddress.value==""){
   // alert(document.MainForm.EMailAddress.type);
    alert('Please Fill In All Values With A *');
    return false;
}else{
   // alert('A2');
    try{
    //alert('A3');
        if(document.MainForm.EMailAddress.type!="'select-one" && document.MainForm.EMailAddress.selectedIndex==0){
                alert('Please Fill In All Values With A *');
                return false;
         }   
    }
    catch(err)
    {
     //   alert('error');
    }
}

    return true;
}