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<div class="miniform"> <div class="{MESSAGE_CLASS}">{STATUSMESSAGE}</div> <div class="{FORM_CLASS}"> <small><CENTER><H1>Contact and Appointment form</center></h1>Items marked with star are required to answer. Attention screen reader users: The star will be read to you if you have some punctuation on in your screen reader.</small> <br/> <form name="form_{SECTION_ID}" id="form_{SECTION_ID}" method="post" action="{URL}" enctype="multipart/form-data"> <input name="miniform" type="hidden" value="{SECTION_ID}"/> <input name="header" type="hidden" value="Berry's Advocates First Contact and Appointment Form"/> <input name="mf_timestamp" type="hidden" value="{DATE} {TIME}"/> <div class="full"> <label for="cupload"><span>Please upload no more than 5 pages describing the case. Pleas no personal health data at this time. <span>*</span></span> <input required="required" class="{CUPLOAD_ERROR}" type="file" id="cupload" name="mf_r_cupload" value="{CUPLOAD}" /> </label> </div> <div class="full"> <label for="format"><span>What format best suits you?</span> <select class="{FORMAT_ERROR}" id="format" name="mf_format"> <option {FORMAT_SELECTED_BRAILLE_FILE+} value="Braille File+">Braille File+</option> <option {FORMAT_SELECTED_LARGE_PRINT+} value="Large Print+">Large Print+</option> <option {FORMAT_SELECTED_RECORDED_AUDIO} value="Recorded Audio">Recorded Audio</option> </select> </label> </div> <div class="full"> <label for="sa1"><span>Your Street Address please? <span>*</span></span> <input placeholder="2222 Boogie boogie Avenue or Ave." required="required" class="{SA1_ERROR}" type="text" id="sa1" name="mf_r_sa1" value="{SA1}" /> </label> </div> <div class="full"> <label for="sa2"><span>Apartment # please: <span>*</span></span> <input placeholder="Apt. 3" required="required" class="{SA2_ERROR}" type="text" id="sa2" name="mf_r_sa2" value="{SA2}" /> </label> </div> <div class="full"> <label for="c"><span>City please: <span>*</span></span> <input placeholder="Worland" required="required" class="{C_ERROR}" type="text" id="c" name="mf_r_c" value="{C}" /> </label> </div> <div class="full"> <label for="sc"><span>Please enter country or state (No abbreviations): <span>*</span></span> <input placeholder="Arkansas or Honduras" required="required" class="{SC_ERROR}" type="text" id="sc" name="mf_r_sc" value="{SC}" /> </label> </div> <div class="full"> <label for="zc"><span>Please enter five digit zip code or your country code? <span>*</span></span> <input placeholder="59101 or Z29H4135B" required="required" class="{ZC_ERROR}" type="text" id="zc" name="mf_r_zc" value="{ZC}" /> </label> </div> <div class="full"> <label for="p1"><span>Please enter your phone Number: <span>*</span></span> <input placeholder="406-555-1212" required="required" class="{P1_ERROR}" type="text" id="p1" name="mf_r_p1" value="{P1}" /> </label> </div> <div class="full"> <label for="vpn"><span>Please verify phone Number: <span>*</span></span> <input placeholder="406-555-1212" required="required" class="{VPN_ERROR}" type="text" id="vpn" name="mf_r_vpn" value="{VPN}" /> </label> </div> <div class="full"> <label for="e1"><span>Please enter your email: <span>*</span></span> <input placeholder="foo@foobar.com" required="required" class="{E1_ERROR}" type="text" id="e1" name="mf_r_e1" value="{E1}" /> </label> </div> <div class="full"> <label for="e2"><span>Please verify your email address for us: <span>*</span></span> <input placeholder="foo@foobar.com" required="required" class="{E2_ERROR}" type="text" id="e2" name="mf_r_e2" value="{E2}" /> </label> </div> <div class="full"> <label for="atime"><span>Please choose the time which works best for first appointment?</span> <div class="grouping {ATIME_ERROR}"> <input type="checkbox" id="i-atime1" {ATIME_8:00_TO_10:00_A.M.} name="mf_atime[]" value="8:00 to 10:00 A.M." /><label for="i-atime1">8:00 to 10:00 A.M.</label><br> <input type="checkbox" id="i-atime2" {ATIME_9:15_TO_11:15} name="mf_atime[]" value="9:15 to 11:15" /><label for="i-atime2">9:15 to 11:15</label><br> <input type="checkbox" id="i-atime3" {ATIME_12:20_TO_2:20} name="mf_atime[]" value="12:20 to 2:20" /><label for="i-atime3">12:20 to 2:20</label><br> <input type="checkbox" id="i-atime4" {ATIME_2:40_TO_4:40_P.M.} name="mf_atime[]" value="2:40 to 4:40 P.M." /><label for="i-atime4">2:40 to 4:40 P.M.</label> <input type="checkbox" id="i-atime5" {ATIME_3:00_TO_4:00_P.M.} name="mf_atime[]" value="3:00 to 4:00 P.M." /><label for="i-atime5">3:00 to 4:00 P.M.</label><br> </div> </label> </div> <div class="full"> <button class="submit" name="Submit" type="submit">Submit to Berry's Advocating.</button> </div> </form> </div> </div>