[include css('forms.css')];

[html-page set-title("Trade In Requests")];


<div id="product-container">
	<h2>Trade In Requests</h2>
	<h3>Customer Information</h3>

	<div style='display: [var error-display];' class='error-group'>
		[var error-message];
	</div>

	<form method='post' action="" id="contact-form" style='display: [var form-display];'>
		<input type="hidden" name="submitted" value="1">
		<input type="hidden" name="formType" value="trade-in">
		<input type="hidden" name="language" value="English">
		<table>
			<tr class='row'>
				<td class='group'>
					<label for='wholename'>Name:</label>
					<input type="text" name='name' id='wholename' class='std-field'  value="[var name];">
				</td>

				<td class='group'>
					<label for='company'>Company:</label>
					<input type="text" name='company' id='company' class='std-field' value="[var company];">
				</td>

				<td class='group'>
					<label for='email'>Email:</label>
					<input type="text" name='from' id='email' class='std-field' value="[var from];">
				</td>
			</tr>


			<tr class='row'>
				<td class='group'>
					<label for='phone'>Phone:</label>
					<input type="text" name='phone' id='phone' class='std-field' value="[var phone];">
				</td>


				<td class='group'>
					<label for='fax'>Fax:</label>
					<input type="text" name='fax' id='fax' class='std-field' value="[var fax];">
				</td>
				
				<td class='group'>
					<label for='address'>Address:</label>
					<input type="text" name='address' id='address' class='std-field' value="[var address];">
				</td>

			</tr>
			
			
			<tr class="row">
			
				<td class='group'>
					<label for='zip'>Zip:</label>
					<input type="text" name='zip' id='zip' class='std-field' value="[var zip];">
				</td>
				<td class='group'>
					<label for='state'>State:</label>
					<select name="state" id='state' title='State' class='std-field'>
						[htmlpage select-options('[var state];', '', [var state-option-params];)];
					</select>
				</td>
			
				<td class='group'>
					<label for='international'>International Countries:</label>
					<input type="text" name='international' id='international' class='std-field' value="[var international];">
				</td>
			</tr>
			
		</table>

		<div class='row'>
			<div class='group'>
				<label>Manufacture Info:</label>

				<input type='radio' name='manufacture' id='atl' value='atl'>
				<label class='std-option' for='atl'>ATL</label>

				<input type='radio' name='manufacture' id='agilent' value='agilent'>
				<label class='std-option' for='agilent'>Agilent/HP</label>

				<input type='radio' name='manufacture' id='ge' value='ge'>
				<label class='std-option' for='ge'>General Electric</label>

				<input type='radio' name='manufacture' id='siemens' value='siemens'>
				<label class='std-option' for='siemens'>Siemens</label>

				<input type='radio' name='manufacture' id='acuson' value='acuson'>
				<label class='std-option' for='acuson'>Acuson</label>

				<input type='radio' name='manufacture' id='toshiba' value='toshiba'>
				<label class='std-option' for='toshiba'>Toshiba</label>

				<input type='radio' name='manufacture' id='medison' value='medison'>
				<label class='std-option' for='medison'>Medison</label>

				<input type='radio' name='manufacture' id='other' value='medison'>
				<label class='std-option' for='other'>Other</label>
			</div>
		</div>



		<div class='row'>
			<div class='group'>
				<label for='brand'>Brand/Systems:</label>
				<input type="text" name='brand' id='brand' class='std-field' value="[var brand];">
			</div>
		</div>
		<div class='row'>
			<div class='group'>
				<label for='condition'>Condition of System:</label><br/>
				<textarea name="condition" id="condition" rows="10" class="std-field" style="width:521px;">[var condition];</textarea>
			</div>
		</div>

	<table>
		<tr class='row'>
			<h3>Features:</h3>

			<td class='group'>
				<label class='std-option' for='doppler'>Doppler</label>
				<input type='checkbox' name='features[]' id='dopplery' value="Dopplery">
			</td>
			<td class='group'>
				<label class='std-option' for='blackwhite'>Black &amp;White</label>
				<input type='checkbox' name='features[]' id='blackwhite' value="Black/White">
			</td>
			<td class='group'>
				<label class='std-option' for='color'>Color</label>
				<input type='checkbox' name='features[]' id='color' value="Color">
			</td>
			<td class='group'>
				<label class='std-option' for='angio'>Color Angio</label>
				<input type='checkbox' name='features[]' id='angio' value="Angio">
			</td>
		</tr>
		<tr class='row'>
			<td class='group'>
				<label class='std-option' for='harmonics'>Harmonics</label>
				<input type='checkbox' name='features[]' id='harmonics' value="Harmonics">
			</td>
			<td class='group'>
				<label class='std-option' for='art'>Art</label>
				<input type='checkbox' name='features[]' id='art' value="Art">
			</td>
			<td class='group'>
				<label class='std-option' for='3d4d'>3D/4D</label>
				<input type='checkbox' name='features[]' id='3d4d' value="3d4d">
			</td>
			<td class='group'>
				<label class='std-option' for='stress'>Stress Echo</label>
				<input type='checkbox' name='features[]' id='stress' value="Stress">
			</td>
		</tr>
	</table>


	<div class='row'>
		<div class='group'>
			<label for='condition'>Other:</label><br/>
			<textarea name="other-features" id="other" rows="5" class="std-field" style="width:521px;">[var other-features];</textarea>
		</div>
	</div>


		<table id="probes"cellspacing="0" cellpadding="0">
			<thead>
				<tr><th class="table-center" colspan="3">Probes</th></tr>
				<tr>
					<th>Model</th>
					<th>Type (Phased Array, Linear, Convex, etc.)</th>
					<th>Serial Number</th>
				</tr>
			</thead>
			<tbody>
				<tr>
					<td>
						<div>
							<label for='model-one'></label>
							<input type="text" name='probe-model[]' id='model-one' class='std-field' value="[var probe-model-0];">
						</div>
					</td>
					<td>
						<div>
							<label for='type-one'></label>
							<input type="text" name='probe-type[]' id='type-one' class='std-field' value="[var probe-type-0];">
						</div>
					</td>
					<td>
						<div>
							<label for='serial-one'></label>
							<input type="text" name='probe-serial[]' id='serial-one' class='std-field' value="[var probe-serial-0];">
						</div>
					</td>
				</tr>

				<tr>
					<td>
						<div>
							<label for='model-two'></label>
							<input type="text" name='probe-model[]' id='model-two' class='std-field' value="[var probe-model-1];">
						</div>
					</td>
					<td>
						<div>
							<label for='type-one'></label>
							<input type="text" name='probe-type[]' id='type-two' class='std-field' value="[var probe-type-1];">
						</div>
					</td>
					<td>
						<div>
							<label for='serial-two'></label>
							<input type="text" name='probe-serial[]' id='serial-two' class='std-field' value="[var probe-serial-1];">
						</div>
					</td>
				</tr>

				<tr>
					<td>
						<div>
							<label for='model-three'></label>
							<input type="text" name='probe-model[]' id='model-three' class='std-field' value="[var probe-model-2];">
						</div>
					</td>
					<td>
						<div>
							<label for='type-three'></label>
							<input type="text" name='probe-type[]' id='type-three' class='std-field' value="[var probe-type-2];">
						</div>
					</td>
					<td>
						<div>
							<label for='serial-three'></label>
							<input type="text" name='probe-serial[]' id='serial-three' class='std-field' value="[var probe-serial-2];">
						</div>
					</td>
				</tr>

				<tr>
					<td>
						<div>
							<label for='model-four'></label>
							<input type="text" name='probe-model[]' id='model-three' class='std-field' value="[var probe-model-3];">
						</div>
					</td>
					<td>
						<div>
							<label for='type-four'></label>
							<input type="text" name='probe-type[]' id='type-four' class='std-field' value="[var probe-type-3];">
						</div>
					</td>
					<td>
						<div>
							<label for='serial-four'></label>
							<input type="text" name='probe-serial[]' id='serial-four' class='std-field' value="[var probe-serial-3];">
						</div>
					</td>
				</tr>
			</tbody>
		</table>
		<table id="bottom-info"cellspacing="0" cellpadding="0">
			<thead>
				<tr>
					<th colspan="3">Model Number</th>
				</tr>
			</thead>
			<tbody>
				<tr>
					<td>
						<label>VCR:</label>
						<input type='radio' name='vcr' id='vcr-yes' value='yes'>
						<label class='std-option' for='vcr-yes'>Yes</label>
					</td>
					<td>
						<input type='radio' name='vcr' id='vcr-no' value='no'>
						<label class='std-option' for='vcr-no'>No</label>
					</td>
					<td>
						<input type="text" name='vcr-model' id='vcr-model' class='std-field' value="[var vcr-model];">
					</td>
				</tr>

				<tr>
					<td>
						<label>B/W Printer</label>
						<input type='radio' name='bw-printer' id='bw-yes' value='yes'>
						<label class='std-option' for='bw-yes'>Yes</label>
					</td>
					<td>
						<input type='radio' name='bw-printer' id='bw-no' value='no'>
						<label class='std-option' for='bw-no'>No</label>
					</td>
					<td>
						<input type="text" name='bw-printer-model' id='bw-model' class='std-field' value="[var bw-printer-model];">
					</td>
				</tr>

				<tr>
					<td>
						<label>Color Printer</label>
						<input type='radio' name='color-printer' id='color-yes' value='yes'>
						<label class='std-option' for='color-yes'>Yes</label>
					</td>
					<td>
						<input type='radio' name='color-printer' id='color-no' value='no'>
						<label class='std-option' for='color-no'>No</label>
					</td>
					<td>
						<input type="text" name='color-printer-model' id='color-model' class='std-field' value="[var color-printer-model];">
					</td>
				</tr>

				<tr>
					<td>
						<label>ECG Cable</label>
						<input type='radio' name='ecg' id='ecg-yes' value='yes'>
						<label class='std-option' for='ecg-yes'>Yes</label>
					</td>
					<td>
						<input type='radio' name='ecg' id='ecg-no' value='no'>
						<label class='std-option' for='ecg-no'>No</label>
					</td>
					<td>
						<input type="text" name='ecg-model' id='ecg-model' class='std-field'>
					</td>
				</tr>

				<tr>
					<td>
						<label>Operation Manual</label>
						<input type='radio' name='operation-manual' id='operation-yes' value='yes'>
						<label class='std-option' for='operation-yes'>Yes</label>
					</td>
					<td>
						<input type='radio' name='operation-manual' id='operation-no' value='no'>
						<label class='std-option' for='operation-no'>No</label>
					</td>
					<td>
						<input type="text" name='operation-manual-model' id='operation-model' class='std-field'>
					</td>
				</tr>
				<tr>
					<td colspan="3">
						<div class="field">
							<INPUT type='image' name="submit" src="/images/contact/submit.gif" title="Submit" alt='submit' class="actionbtn">
							<INPUT type='image' src="/images/contact/reset.gif" title="reset" alt='reset' class='otherbtn'
								onclick='(document.getElementById("contact-form")).reset(); return false;'>
						</div>
					</td>
				</tr>
			</tbody>
		</table>
	</form>
	
	<div style='display: [var notice-display];' class='error-group'>
		<p>To prevent spam, you may only sumbit an application once every 5 minutes.  You will
		be able to submit another application at <em>[var notice-open-time];</em>.
		</p>
	</div>

	<div class="float-catch"></div>
</div>