document.write('		<div id="intake-form">');document.write('			<form id="intakeform" name="myintakeform"');document.write('					action="http://forms.bxlegal.com/intakeform_put.cfm" method="post"');document.write('			>');document.write('				<input type="hidden" name="extLogId" value="1241201">');document.write('				<input type="hidden" name="survey_external_key" value="MyzotmxlzlAq9uO85ZTHdvMmAEyaGLnn5hvJgaJu">');document.write('                            <div class="section">');document.write('                                <table>');document.write('		<tr>');document.write('			<td class="field" valign="top">');document.write('					<span class="label">');document.write('						Email Address <font color="red">*</font> ');document.write('					</span>');document.write('					<br />');document.write('		<input name="answer_1_1" type="text" maxlength="60" id="answer_1_1" title="Email Address"');document.write('				value=""');document.write('		>');document.write('			</td>');document.write('		</tr>');document.write('		<tr>');document.write('			<td class="field" valign="top">');document.write('					<span class="label">');document.write('						Your Name <font color="red">*</font> ');document.write('					</span>');document.write('					<br />');document.write('		<input name="answer_1_2" type="text" maxlength="60" id="answer_1_2" title="Your Name"');document.write('				value=""');document.write('		>');document.write('			</td>');document.write('		</tr>');document.write('		<tr>');document.write('			<td class="field" valign="top">');document.write('					<span class="label">');document.write('						Website <font color="red">*</font> ');document.write('					</span>');document.write('					<br />');document.write('		<input name="answer_1_3" type="text" maxlength="60" id="answer_1_3" title="Website"');document.write('				value=""');document.write('		>');document.write('			</td>');document.write('		</tr>');document.write('		<tr>');document.write('			<td class="field" valign="top">');document.write('					<span class="label">');document.write('						Browser Used <font color="red">*</font> ');document.write('					</span>');document.write('					<br />');document.write('			<select name="answer_1_4" id="answer_1_4" title="Browser Used"  >');document.write('					<option value=" ">- Select -</option>');document.write('						<option value="Internet Explorer 8"> Internet Explorer 8&nbsp;&nbsp;</option>');document.write('						<option value="Internet Explorer 7"> Internet Explorer 7&nbsp;&nbsp;</option>');document.write('						<option value="Internet Explorer (other)"> Internet Explorer (other)&nbsp;&nbsp;</option>');document.write('						<option value="Firefox"> Firefox&nbsp;&nbsp;</option>');document.write('						<option value="Chrome"> Chrome&nbsp;&nbsp;</option>');document.write('						<option value="Safari"> Safari&nbsp;&nbsp;</option>');document.write('						<option value="iPhone"> iPhone&nbsp;&nbsp;</option>');document.write('						<option value="Other"> Other&nbsp;&nbsp;</option>');document.write('			</select>');document.write('			</td>');document.write('		</tr>');document.write('		<tr>');document.write('			<td class="field" valign="top">');document.write('					<span class="label">');document.write('						Description <font color="red">*</font> ');document.write('					</span>');document.write('					<br />');document.write('		<textarea name="answer_1_5" rows="5" id="answer_1_5" title="Description"');document.write('		></textarea>');document.write('			</td>');document.write('		</tr>');document.write('		<tr>');document.write('			<td class="field" valign="top">');document.write('					<span class="label">');document.write('						Steps to Reproduce ');document.write('					</span>');document.write('					<br />');document.write('		<textarea name="answer_1_6" rows="5" id="answer_1_6" title="Steps to Reproduce"');document.write('		></textarea>');document.write('			</td>');document.write('		</tr>');document.write('                </table>');document.write('                </div>');document.write('                <div class="section">');document.write('                    <table>');document.write('                        <tr>');document.write('                            <td class="field">');document.write('                                    <input name="survey_submit_continue" id="intakeform-submit" type="submit" value="Submit" onClick="javascript:');document.write('var errortxt = \'\';');document.write('var focusobj = null;');document.write('var theobj = null;');document.write('function getobj(id,item) {');document.write('	theobj = document.getElementById(\'answer_\'+id+\'_\'+item);');document.write('}');document.write('function getobjx(id,item,i) {');document.write('	theobj = document.getElementById(\'answer_\'+id+\'_\'+item+\'_\'+i);');document.write('}');document.write('function isCheckCaptcha(id,item) {');document.write('	theobj = document.getElementById(\'validate_\'+id+\'_\'+item);');document.write('	if (theobj) {');document.write('		thekey = theobj.value;');document.write('		getobj(id,item);');document.write('		if (theobj) {');document.write('			if (theobj.value == thekey) {');document.write('				return true;');document.write('			}');document.write('		}');document.write('	}');document.write('	return false;');document.write('}');document.write('function isCheckEmpty(id,item) {');document.write('	var myresult=true;');document.write('	var i=1;');document.write('	while (1) {');document.write('		getobjx(id,item,i);');document.write('		if (theobj == null) {');document.write('			break;');document.write('		} else if (theobj.checked || theobj.disabled) {');document.write('			myresult = false;');document.write('			break;');document.write('		}');document.write('		i = i + 1;');document.write('	}');document.write('	getobjx(id,item,1);');document.write('	return myresult;');document.write('}');document.write('function isDate(id,item) {');document.write('	getobj(id,item);');document.write('	if (!theobj.disabled && (theobj.value.length > 0)) {');document.write('		if (!isMask(id,item,\'99/99/9999\')) {');document.write('			return false;');document.write('		}');document.write('		val = theobj.value.substr(0,2);');document.write('		if ((val < 1) || (val > 12)) {');document.write('			return false;');document.write('		}');document.write('		val = theobj.value.substr(3,2);');document.write('		if ((val < 1) || (val > 31)) {');document.write('			return false;');document.write('		}');document.write('		val = theobj.value.substr(6,4);');document.write('		if ((val < 1900) || (val > 2030)) {');document.write('			return false;');document.write('		}');document.write('	}');document.write('	return true;');document.write('}');document.write('function isFloat(id,item) {');document.write('	getobj(id,item);');document.write('	return (!theobj.disabled && (theobj.value.length == 0) || (theobj.value.toString().search(/^\d{1,5}(\.\d{1,2})?$/) == 0));');document.write('}');document.write('function isInputEmpty(id,item) {');document.write('	getobj(id,item);');document.write('	return (!theobj.disabled && (theobj.value == \'\') || (theobj.value == \'Enter \' + theobj.title));');document.write('}');document.write('function isInteger(id,item) {');document.write('	getobj(id,item);');document.write('	return (!theobj.disabled && (theobj.value.length == 0) || (theobj.value.toString().search(/^[0-9]+$/) == 0));');document.write('}');document.write('function isMask(id,item,mask) {');document.write('	getobj(id,item);');document.write('	if (!theobj.disabled && (theobj.value.length > 0)) {');document.write('		if (theobj.value.length != mask.length) {');document.write('			return false;');document.write('		}');document.write('		for (i=0; i < mask.length; i++) {');document.write('			switch (mask[i]) {');document.write('				case \'9\':');document.write('					if ((theobj.value[i] < \'0\') || (theobj.value[i] > \'9\')) {');document.write('						return false;');document.write('					}');document.write('					break;');document.write('				case \'A\':');document.write('					if ((theobj.value[i] < \'A\') || (theobj.value[i] > \'Z\')) {');document.write('						return false;');document.write('					}');document.write('					break;');document.write('				case \'.\':');document.write('					break;');document.write('				default:');document.write('					if (theobj.value[i] != mask[i]) {');document.write('						return false;');document.write('					}');document.write('					break;');document.write('			}');document.write('		}');document.write('	}');document.write('	return true;');document.write('}');document.write('function isSelectEmpty(id,item) {');document.write('	getobj(id,item);');document.write('	return (!theobj.disabled && (theobj.value == \' \'));');document.write('}');document.write('function seterr(txt) {');document.write('	errortxt = errortxt + theobj.title + \' \' + txt + lf;');document.write('	if (focusobj == null) {');document.write('		focusobj = theobj;');document.write('	}');document.write('}');document.write('var lf = \'\\n\';if (isInputEmpty(\'1\',\'1\')) {seterr(\'must be provided\');}if (isInputEmpty(\'1\',\'2\')) {seterr(\'must be provided\');}if (isInputEmpty(\'1\',\'3\')) {seterr(\'must be provided\');}if (isSelectEmpty(\'1\',\'4\')) {seterr(\'must be selected\');}if (isInputEmpty(\'1\',\'5\')) {seterr(\'must be provided\');}');document.write('if (errortxt != \'\') {');document.write('	alert(errortxt);');document.write('	if (focusobj) {');document.write('		focusobj.focus();');document.write('	}');document.write('	return false;');document.write('}');document.write('return true;');document.write('" />');document.write('                            </td>');document.write('                        </tr>');document.write('                    </table>');document.write('                </div>');document.write('			</form>');document.write('		</div>');