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 name="extLogId" type="hidden" value="559192">');document.write('									<div class="section">');document.write('										<table>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_1" type="text" maxlength="60" id="answer_1" title="Name"');document.write('																onfocus="if(this.value==\'Enter Name\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter Name\';"');document.write('																	value="Enter Name"');document.write('														>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_2" type="text" maxlength="60" id="answer_2" title="Street Address"');document.write('																onfocus="if(this.value==\'Enter Street Address\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter Street Address\';"');document.write('																	value="Enter Street Address"');document.write('														>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_3" type="text" maxlength="60" id="answer_3" title="City"');document.write('																onfocus="if(this.value==\'Enter City\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter City\';"');document.write('																	value="Enter City"');document.write('														>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('													<select name="answer_4" id="answer_4" title="State">');document.write('														<option value="AL" >Alabama&nbsp;</option>');document.write('														<option value="AK" >Alaska&nbsp;</option>');document.write('														<option value="AZ" >Arizona&nbsp;</option>');document.write('														<option value="AR" >Arkansas&nbsp;</option>');document.write('														<option value="CA" >California&nbsp;</option>');document.write('														<option value="CO" >Colorado&nbsp;</option>');document.write('														<option value="CT" >Connecticut&nbsp;</option>');document.write('														<option value="DE" >Delaware&nbsp;</option>');document.write('														<option value="DC" >Dist. of Columbia&nbsp;</option>');document.write('														<option value="FL" >Florida&nbsp;</option>');document.write('														<option value="GA" >Georgia&nbsp;</option>');document.write('														<option value="HI" >Hawaii&nbsp;</option>');document.write('														<option value="ID" >Idaho&nbsp;</option>');document.write('														<option value="IL" >Illinois&nbsp;</option>');document.write('														<option value="IN" >Indiana&nbsp;</option>');document.write('														<option value="IA" >Iowa&nbsp;</option>');document.write('														<option value="KS" >Kansas&nbsp;</option>');document.write('														<option value="KY" >Kentucky&nbsp;</option>');document.write('														<option value="LA" >Louisiana&nbsp;</option>');document.write('														<option value="ME" >Maine&nbsp;</option>');document.write('														<option value="MD" >Maryland&nbsp;</option>');document.write('														<option value="MA" >Massachusetts&nbsp;</option>');document.write('														<option value="MI" >Michigan&nbsp;</option>');document.write('														<option value="MN" >Minnesota&nbsp;</option>');document.write('														<option value="MS" >Mississippi&nbsp;</option>');document.write('														<option value="MO" >Missouri&nbsp;</option>');document.write('														<option value="MT" >Montana&nbsp;</option>');document.write('														<option value="NE" >Nebraska&nbsp;</option>');document.write('														<option value="NV" >Nevada&nbsp;</option>');document.write('														<option value="NH" >New Hampshire&nbsp;</option>');document.write('														<option value="NJ" >New Jersey&nbsp;</option>');document.write('														<option value="NM" >New Mexico&nbsp;</option>');document.write('														<option value="NY" >New York&nbsp;</option>');document.write('														<option value="NC" >North Carolina&nbsp;</option>');document.write('														<option value="ND" >North Dakota&nbsp;</option>');document.write('														<option value="OH" >Ohio&nbsp;</option>');document.write('														<option value="OK" >Oklahoma&nbsp;</option>');document.write('														<option value="OR" >Oregon&nbsp;</option>');document.write('														<option value="PA" >Pennsylvania&nbsp;</option>');document.write('														<option value="RI" >Rhode Island&nbsp;</option>');document.write('														<option value="SC" >South Carolina&nbsp;</option>');document.write('														<option value="SD" >South Dakota&nbsp;</option>');document.write('														<option value="TN" >Tennessee&nbsp;</option>');document.write('														<option value="TX" selected>Texas&nbsp;</option>');document.write('														<option value="UT" >Utah&nbsp;</option>');document.write('														<option value="VT" >Vermont&nbsp;</option>');document.write('														<option value="VA" >Virginia&nbsp;</option>');document.write('														<option value="WA" >Washington&nbsp;</option>');document.write('														<option value="WV" >West Virginia&nbsp;</option>');document.write('														<option value="WI" >Wisconsin&nbsp;</option>');document.write('														<option value="WY" >Wyoming&nbsp;</option>');document.write('													</select>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_5" type="text" maxlength="60" id="answer_5" title="Zip"');document.write('																onfocus="if(this.value==\'Enter Zip\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter Zip\';"');document.write('																	value="Enter Zip"');document.write('														>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_6" type="text" maxlength="60" id="answer_6" title="Phone"');document.write('																onfocus="if(this.value==\'Enter Phone\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter Phone\';"');document.write('																	value="Enter Phone"');document.write('														>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_7" type="text" maxlength="60" id="answer_7" title="Fax"');document.write('																onfocus="if(this.value==\'Enter Fax\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter Fax\';"');document.write('																	value="Enter Fax"');document.write('														>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('														<input name="answer_8" type="text" maxlength="60" id="answer_8" title="Email Address"');document.write('																onfocus="if(this.value==\'Enter Email Address\')this.value=\'\';this.select()"');document.write('																onblur="if(this.value==\'\')this.value=\'Enter Email Address\';"');document.write('																	value="Enter Email Address"');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('                                                            How would you like to be contacted <font color="red">*</font>');document.write('                                                        </span>');document.write('                                                        <br />');document.write('														<input name="answer_9" type="checkbox" value="Email" id="answer_9_1" title="How would you like to be contacted"');document.write('															 style="width:16px"');document.write('														>');document.write('															<span class="option">Email</span><br>');document.write('														<input name="answer_9" type="checkbox" value="Phone" id="answer_9_2" title="How would you like to be contacted"');document.write('															 style="width:16px"');document.write('														>');document.write('															<span class="option">Phone</span><br>');document.write('														<input name="answer_9" type="checkbox" value="Fax" id="answer_9_3" title="How would you like to be contacted"');document.write('															 style="width:16px"');document.write('														>');document.write('															<span class="option">Fax</span><br>');document.write('														<input name="answer_9" type="checkbox" value="Postal Mail" id="answer_9_4" title="How would you like to be contacted"');document.write('															 style="width:16px"');document.write('														>');document.write('															<span class="option">Postal Mail</span><br>');document.write('									</td>');document.write('								</tr>');document.write('								<tr>');document.write('									<td class="field" valign="top">');document.write('												<textarea name="answer_10" rows="5" id="answer_10" title="Brief description of your legal issue"');document.write('														onfocus="if(this.value==\'Enter Brief description of your legal issue\')this.value=\'\';this.select()"');document.write('														onblur="if(this.value==\'\')this.value=\'Enter Brief description of your legal issue\';"');document.write('												>Enter Brief description of your legal issue</textarea>');document.write('									</td>');document.write('								</tr>');document.write('							<tr>');document.write('								<td class="field">');document.write('									<input type="hidden" name="survey_external_key" value="PFWoTMHHNCylXgfGKhzTcV1dLbMpbGhcjezhFHhh">');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) {');document.write('	theobj = document.getElementById(\'answer_\'+id);');document.write('}');document.write('function isCheckEmpty(id) {');document.write('	var myobj=null;');document.write('	var myresult=true;');document.write('	var i=1;');document.write('	while (1) {');document.write('		myobj = document.getElementById(\'answer_\'+id+\'_\'+i);');document.write('		if (myobj == null) {');document.write('			break;');document.write('		}');document.write('		if (myobj.checked) {');document.write('			myresult = false;');document.write('			break;');document.write('		}');document.write('		i = i + 1;');document.write('	}');document.write('	getobj(id+\'_1\');');document.write('	return myresult;');document.write('}');document.write('function isDate(id) {');document.write('	getobj(id);');document.write('	if (theobj.value.length > 0) {');document.write('		if (!isMask(id,\'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) {');document.write('	getobj(id);');document.write('	return ((theobj.value.length == 0) || (theobj.value.toString().search(/^\d{1,5}(\.\d{1,2})?$/) == 0));');document.write('}');document.write('function isInputEmpty(id) {');document.write('	getobj(id);');document.write('	return ((theobj.value == \'\') || (theobj.value == \'Enter \' + theobj.title));');document.write('}');document.write('function isInteger(id) {');document.write('	getobj(id);');document.write('	return ((theobj.value.length == 0) || (theobj.value.toString().search(/^[0-9]+$/) == 0));');document.write('}');document.write('function isMask(id,mask) {');document.write('	getobj(id);');document.write('	if (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) {');document.write('	getobj(id);');document.write('	return (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\')) {seterr(\'must be provided\');}if (isInputEmpty(\'3\')) {seterr(\'must be provided\');}if (isInputEmpty(\'5\')) {seterr(\'must be provided\');}if (isInputEmpty(\'8\')) {seterr(\'must be provided\');}if (isCheckEmpty(\'9\')) {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>');