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<p align="center"><b><font size="5">Contact Us</font></b></p>
<p align="center"><font color="666666"><b>We are interested in hearing from you. This information is kept confidential and is only used to improve our site and keep customer satisfaction high. If you would like us to respond to your comments, you need to include your email address.</b></font> </p>
<form method="post" action="contactus_action.cfm">
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<table width="588" border="0" align="center" cellpadding="4">
<tr>
<td width="122" align="left" bgcolor="#FFFFCC"><b><font size="-1" color="666666">First
Name</font></b></td>
<td width="288" align="left" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="text" size="40" name="first">
</font></b></td>
</tr>
<tr>
<td width="122" align="left" bgcolor="#FFFFFF"><font color="666666"><b><font size="-1">Last
Name</font></b></font></td>
<td width="288" align="left" bgcolor="#FFFFFF" bordercolor="#FFFFFF"><b><font color="666666">
<input type="text" size="40" name="Last">
</font></b></td>
</tr>
<tr>
<td width="122" align="left" bgcolor="#FFFFCC"><b><font size="-1" color="666666">Email
Address</font></b></td>
<td width="288" align="left" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="text" size="25" name="Email">
</font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFFF"><b><font size="-1" color="666666">Street
Address</font></b></td>
<td align="left" width="288" bgcolor="#FFFFFF"> <b><font color="666666">
<input type="text" size="40" name="Street">
</font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFCC"><b><font size="-1" color="666666">City</font></b></td>
<td align="left" width="288" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="text" size="40" name="City">
</font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFFF"><b><font size="-1" color="666666">State</font></b></td>
<td align="left" width="288" bgcolor="#FFFFFF"> <b><font color="666666">
<select name="State">
<option value="AL" selected>ALABAMA
<option value="AK">ALASKA
<option value="AZ">ARIZONA
<option value="AR">ARKANSAS
<option value="CA">CALIFORNIA
<option value="CO">COLORADO
<option value="CT">CONNECTICUT
<option value="DE">DELAWARE
<option value="DC">DISTRICT OF COLUMBIA
<option value="FL">FLORIDA
<option value="GA">GEORGIA
<option value="HI">HAWAII
<option value="ID">IDAHO
<option value="IL">ILLINOIS
<option value="IN">INDIANA
<option value="IA">IOWA
<option value="KS">KANSAS
<option value="KY">KENTUCKY
<option value="LA">LOUISIANA
<option value="ME">MAINE
<option value="MD">MARYLAND
<option value="MA">MASSACHUSETTS
<option value="MI">MICHIGAN
<option value="MN">MINNESOTA
<option value="MS">MISSISSIPPI
<option value="MO">MISSOURI
<option value="MT">MONTANA
<option value="NE">NEBRASKA
<option value="NV">NEVADA
<option value="NH">NEW HAMPSHIRE
<option value="NJ">NEW JERSEY
<option value="NM">NEW MEXICO
<option value="NY">NEW YORK
<option value="NC">NORTH CAROLINA
<option value="ND">NORTH DAKOTA
<option value="OH">OHIO
<option value="OK">OKLAHOMA
<option value="OR">OREGON
<option value="PA">PENNSYLVANIA
<option value="PR">PUERTO RICO
<option value="RI">RHODE ISLAND
<option value="SC">SOUTH CAROLINA
<option value="SD">SOUTH DAKOTA
<option value="TN">TENNESSEE
<option value="TX">TEXAS
<option value="UT">UTAH
<option value="VT">VERMONT
<option value="VI">VIRGIN ISLANDS
<option value="VA">VIRGINIA
<option value="WA">WASHINGTON
<option value="WV">WEST VIRGINIA
<option value="WI">WISCONSIN
<option value="WY">WYOMING
</select>
</font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFCC"><b><font size="-1" color="666666">Zip
Code</font></b></td>
<td align="left" width="288" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="text" size="15" name="Zip" maxlength="15">
</font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFFF"><b><font size="-1" color="666666">Home
Phone</font></b></td>
<td align="left" width="288" bgcolor="#FFFFFF"> <b><font color="666666">
<input type="text" size="15" name="hPhone" maxlength="15">
</font></b></td>
</tr>
<tr>
<td align="left" height="37" width="122" bgcolor="#FFFFCC"><b><font size="-1" color="666666">Work
Phone</font></b></td>
<td align="left" height="37" width="288" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="text" size="15" name="wPhone" maxlength="15">
</font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFFF" valign="top"><b><font size="-1" color="666666">Sex<br>
</font></b><font size="-1" color="666666"><font size="-2" color="#FF3333">(optional)</font></font></td>
<td align="left" width="288" bgcolor="#FFFFFF" valign="top"> <b><font color="666666">
<input type="radio" name="sex" value="Female">
<font size="-1">female</font><br>
<input type="radio" name="sex" value="Male">
<font size="-1">male</font> </font></b></td>
</tr>
<tr>
<td align="left" width="122" bgcolor="#FFFFCC"><b><font size="-1" color="666666">Your
Age <font size="-2"><br>
</font></font></b><font size="-1" color="666666"><font size="-2"><font color="#FF3333">(optional)</font></font></font></td>
<td align="left" width="288" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="text" size="15" name="Age" maxlength="15">
</font></b></td>
</tr>
</table>
<center>
<table width="589" cellpadding="4">
<tr bgcolor="#FFFFCC">
<td align="left" colspan="2" valign="top" bgcolor="#FFFFFF"><b><font size="-1" color="666666">Are
you currently researching arch support options?</font></b></td>
<td width="363" bgcolor="#FFFFFF"> <b><font color="666666">
<input type="radio" name="support" value="Yes">
<font size="-1"> yes<br>
<input type="radio" name="support" value="No">
no </font></font></b></td>
</tr>
<tr>
<td align="left" colspan="2" valign="top" bgcolor="#FFFFCC"><b><font size="-1" color="666666">Have
you bought anything online, in the last week, month, 3 months, year?</font></b></td>
<td width="363" bgcolor="#FFFFCC"> <b><font color="666666">
<select name="time">
<option value="Last Week" selected>Last Week
<option value="Last Month">Last Month
<option value="Last Three Months">Last Three Months
<option value="Last Year">Last Year
</select>
<!--<input type="radio" name="" value="">
<font size="-1">yes<br>
<input type="radio" name="" value="">
no---> </font></font></b></td>
</tr>
<tr bgcolor="#FFFFCC">
<td align="left" colspan="2" valign="top" bgcolor="#FFFFFF"><b><font size="-1" color="666666">Have
you been given a diagnosis?<br>
<br>
If so, what is it? </font><font color="666666">
<input type="text" size="40" name="diagnosis1">
</font></b></td>
<td width="363" bgcolor="#FFFFFF" valign="top"> <b><font color="666666">
<input type="radio" name="diagnosis" value="Yes">
<font size="-1">yes<br>
<input type="radio" name="diagnosis" value="No">
no </font></font></b></td>
</tr>
<tr bgcolor="#FFFFCC">
<td align="left" colspan="3" valign="top"><b><font size="-1" color="666666">
</font></b></td>
</tr>
<tr bgcolor="#FFFFFF">
<td align="left" colspan="3" height="53"><b><font size="-1" color="666666">What
is most important to you when choosing products online? <br>
</font><font color="666666">
<textarea name="products" rows=8 cols=70></textarea>
</font></b></td>
</tr>
<tr bgcolor="#FFFFCC">
<td align="left" colspan="3" valign="top" height="42"><b><font size="-1" color="666666">How
did you find this site? </font><font color="666666">
<input type="text" size="40" name="site">
</font></b></td>
</tr>
<tr valign="top" bgcolor="#FFFFFF">
<td align="left" colspan="3" height="31"><b><font size="-1" color="666666">How
could this site be more useful to you? </font><font color="666666">
<br>
<textarea name="comment" rows=8 cols=70></textarea>
</font></b></td>
</tr>
<tr>
<td align="left" colspan="2" height="51" valign="top" bgcolor="#FFFFCC"><b><font size="-1" color="666666">Would
you like to be notified of site updates and new offerrings? </font></b></td>
<td width="363" height="51" valign="top" bgcolor="#FFFFCC"> <b><font color="666666">
<input type="radio" name="offering" value="Yes">
<font size="-1">yes</font><br>
<input type="radio" name="offering" value="No">
<font size="-1">no </font></font></b></td>
</tr>
<tr bgcolor="#FFFFFF" valign="top">
<td align="left" colspan="3" height="36"><b><font size="-1" color="666666">What
search word(s) did you use to find this site? </font><font color="666666">
<input type="text" size="40" name="search">
</font><font size="-1" color="666666"> </font></b></td>
</tr>
<tr>
<td align="left" colspan="2" valign="top" bgcolor="#FFFFCC"><b><font size="-1" color="666666">What
search engines do you use most often for searching information on the
web?</font></b></td>
<td width="363" valign="top" bgcolor="#FFFFCC">
<p> <b><font size="-1" color="666666">
<input type="checkbox" name="engine" value="Yahoo">
Yahoo<br>
<input type="checkbox" name="engine" value="Excite">
Excite<br>
<input type="checkbox" name="engine" value="Lycos">
Lycos<br>
<input type="checkbox" name="engine" value="AltaVista">
AltaVista<br>
<input type="checkbox" name="engine" value="GoTo.com">
GoTo.com<br>
<input type="checkbox" name="engine" value="Snap">
Snap<br>
<input type="checkbox" name="engine" value="LookSmart">
LookSmart <br>
<input type="checkbox" name="engine" value="Google">
Google<br>
<input type="checkbox" name="engine" value="HotBot">
HotBot<br>
<input type="checkbox" name="engine" value="About.com">
About.com<br>
<input type="checkbox" name="engine" value="Netscape">
Netscape<br>
Other </font><font color="666666">
<input type="text" size="15" name="eother" maxlength="15">
</font></b></p>
</td>
</tr>
<tr bgcolor="#FFFFFF">
<td align="left" colspan="3"><b><font size="-1" color="666666"> Would
you like more information about....? </font><font color="666666"> <br>
<textarea name="info" rows=8 cols=70></textarea>
</font></b></td>
</tr>
<tr align="center" valign="top">
<td colspan="3" height="101"><b><font color="666666"><br>
<font size="-1">TheArchSupport.com<br>
P.O. Box 1467 <br>
Rockville, MD 20849<br>
Call Toll Free 1-877-375-ARCH (2724) </font></font></b></td>
</tr>
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