All pastes #498794 Raw Edit

Customer Complaint

public text v1 · immutable
·published 2007-05-20 17:51 UTC
rendered paste body
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<html>
<head>
<base href="http://fs2.formsite.com//chwebb1/" />
<meta http-equiv="Content-Type" content="text/html;CHARSET=iso-8859-1" />
<title>Customer Complaint</title>

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<!--ENDOFADD -->
<form action="http://fs2.formsite.com/form_app/FormSite" method="post" enctype="application/x-www-form-urlencoded" id="FSForm">
<div style="display:none;">
<input type="hidden" name="FormId" size="-1" value="FormResult" />
<input type="hidden" name="UserNbr" size="-1" value="200776" />
<input type="hidden" name="FormNbr" size="-1" value="4" />
<input type="text" name="subject_line" />
<input type="hidden" name="FormKey" size="-1" value="682298422" />
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<br class="clear"/>

<div id="q0" class="q full_width">
<a name="ItemAnchor0"></a>
<div style="padding-left:5px;padding-right:5px;position:relative;left:-1px;"><div style="min-height:150px;width:100%;text-align:center;border:1px solid #000000;background-color:#FFFFFF;color:#000000;"><img src="/images/stock/headerChooser/13Computers_typing_r_000000_FFFFFF.jpg" alt="13Computers_typing_r_000000_FFFFFF.jpg" style="float:right" /><div class="titleText"><p style="margin-top:10px;padding-top:0px;font-size:36px;">Customer Complaint Form</p></div></div></div>
</div>

<br class="clear"/>

<div id="q1" class="q required">
<a name="ItemAnchor1"></a>
Thank you for using SquareMint Design. We sincerely apologize for any problems that you encountered during your visit. Please fill in the information below to help us understand what went wrong so that we can make things right.
</div>

<br class="clear"/>

<div id="q2" class="q required">
<a name="ItemAnchor2"></a>
<label class="question top_question" for="RESULT_TextField-2"><span class="icon">&nbsp;</span>First Name</label>
<input type="text" name="RESULT_TextField-2" size="25" class="text_field" id="RESULT_TextField-2" />
</div>

<div id="q3" class="q required">
<a name="ItemAnchor3"></a>
<label class="question top_question" for="RESULT_TextField-3"><span class="icon">&nbsp;</span>Last Name</label>
<input type="text" name="RESULT_TextField-3" size="25" class="text_field" id="RESULT_TextField-3" />
</div>

<br class="clear"/>

<div id="q4" class="q required">
<a name="ItemAnchor4"></a>
<label class="question top_question" for="RESULT_TextField-4"><span class="icon">&nbsp;</span>Address 1</label>
<input type="text" name="RESULT_TextField-4" size="25" class="text_field" id="RESULT_TextField-4" />
</div>

<br class="clear"/>

<div id="q5" class="q">
<a name="ItemAnchor5"></a>
<label class="question top_question" for="RESULT_TextField-5">Address 2<span class="icon">&nbsp;</span></label>
<input type="text" name="RESULT_TextField-5" size="25" class="text_field" id="RESULT_TextField-5" />
</div>

<br class="clear"/>

<div id="q6" class="q required">
<a name="ItemAnchor6"></a>
<label class="question top_question" for="RESULT_TextField-6"><span class="icon">&nbsp;</span>City</label>
<input type="text" name="RESULT_TextField-6" size="25" class="text_field" id="RESULT_TextField-6" />
</div>

<div id="q7" class="q required">
<a name="ItemAnchor7"></a>
<label class="question top_question" for="RESULT_TextField-7"><span class="icon">&nbsp;</span>State</label>
<input type="text" name="RESULT_TextField-7" size="2" class="text_field" id="RESULT_TextField-7" maxlength="2" />
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<div id="q8" class="q required">
<a name="ItemAnchor8"></a>
<label class="question top_question" for="RESULT_TextField-8"><span class="icon">&nbsp;</span>Postal Code</label>
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<br class="clear"/>

<div id="q9" class="q">
<a name="ItemAnchor9"></a>
<label class="question top_question" for="RESULT_TextField-9">Phone<span class="icon">&nbsp;</span></label>
<input type="text" name="RESULT_TextField-9" size="25" class="text_field" id="RESULT_TextField-9" />
</div>

<br class="clear"/>

<div id="q10" class="q">
<a name="ItemAnchor10"></a>
<label class="question top_question" for="RESULT_TextField-10">Email Address<span class="icon">&nbsp;</span></label>
<input type="text" name="RESULT_TextField-10" size="25" class="text_field" id="RESULT_TextField-10" />
</div>

<br class="clear"/>

<div id="q11" class="q full_width">
<a name="ItemAnchor11"></a>
<hr/>
</div>

<br class="clear"/>

<div id="q12" class="q required">
<a name="ItemAnchor12"></a>
<label class="question top_question" for="RESULT_TextField-12"><span class="icon">&nbsp;</span>Date of Incident (MM/DD/YYYY)</label>
<input type="text" name="RESULT_TextField-12" size="10" class="text_field" id="RESULT_TextField-12" maxlength="10" />
</div>

<br class="clear"/>

<div id="q13" class="q required">
<a name="ItemAnchor13"></a>
<label class="question top_question" for="RESULT_TextArea-13"><span class="icon">&nbsp;</span>Please describe what happened. Be as detailed as possible and write as much as you would like.</label>
<textarea name="RESULT_TextArea-13" rows="10" cols="65" class="text_field" id="RESULT_TextArea-13"></textarea>
</div>

<br class="clear"/>

<div id="q14" class="q">
<a name="ItemAnchor14"></a>
<label class="question top_question" for="RESULT_TextArea-14">What do you feel would be a fair resolution to the situation that occurred?<span class="icon">&nbsp;</span></label>
<textarea name="RESULT_TextArea-14" rows="10" cols="65" class="text_field" id="RESULT_TextArea-14"></textarea>
</div>

<br class="clear"/>

<div class="q required"><span class="icon">&nbsp;</span>Indicates Response Required
</div>
<br class="clear"/>

</div>
<div class="outside_container"><input type="submit" name="Submit" value="Submit" class="submit_button" id="FSsubmit" /></div>
<BR><BR><TABLE BORDER="0" CELLSPACING="0" CELLPADDING="2" WIDTH="100%"><TR><TD HEIGHT="4" BGCOLOR="#3D8BFF" COLSPAN="2"></TD></TR><TR><TD style="background-color: #fff; color: #000">This form created at <a href="http://www.formsite.com/app/FormSite?FormId=LoadIndex&AdSource=999001" target="_blank" style="color: #0000FF">http://www.formsite.com/</a></TD><TD BGCOLOR="#FFFFFF" align="right"><A HREF="http://www.passwordprotection.com/" target="_blank" style="color: #0000FF">Password Protect Web Content</A></TD></TR></TABLE><BR></form>
</body>
</html>