{ include file="location.tpl" last_location="service"} 
{capture name=dialog} 

<!-- BEGIN CONTENT -->
<br><br>
<big><b>Request a Service Call</b></big>
<br><br>
<FORM method="POST" action="/cgi-bin/cgiemail/service.txt">

<INPUT TYPE="hidden" NAME="cgiemail-mailopt" VALUE="sync">
<INPUT TYPE="hidden" NAME="generalemail" VALUE="info@midwestvending.com">
<INPUT TYPE="hidden" NAME="subject" VALUE="**Service Request from website**">

<table border="0" width="360">
<tr>
<td align="right" class="contentbar1">First Name:</td><td><INPUT TYPE="text" NAME="firstname" size=20></td>
</tr>
<tr>
<td align="right" class="contentbar1">Last Name:</td><td><INPUT TYPE="text" NAME="lastname" size=20></td>
</tr>
<tr>
<td align="right" class="contentbar1">Organization:</td><td><INPUT TYPE="text" NAME="org" size=20></td>
</tr>
<tr>
<td align="right" class="contentbar1">Address:</td><td><INPUT TYPE="text" NAME="address" size=20></td>
</tr>
<tr>
<td align="right" class="contentbar1">e-Mail:</td><td><INPUT TYPE="text" NAME="email" size=20></td>
</tr>
<tr>
<td align="right" class="contentbar1">Phone:</td><td><INPUT TYPE="text" NAME="phone" size=20></td>
</tr>
<tr>
<td align="right" class="contentbar1">Machine Type:</td><td>
<select size="1" name="machinetype">
<option>Snack Machine</option>
<option>Change Machine</option>
<option>Cold Food Machine</option>
<option>Pop/Soda Machine</option>
<option>Coffee Machine</option>
</select>
</td>
</tr>
<tr>
<td align="right" class="contentbar1">Description of Problem:</td><td><TEXTAREA WRAP=PHYSICAL NAME="comments" ROWS=5 COLS=30></TEXTAREA></td>
</tr>
</table>

<INPUT TYPE="submit" VALUE="Send"><INPUT TYPE="reset" VALUE="Clear">

</FORM>
<!-- END CONTENT -->

{/capture} 
{ include file="dialog.tpl" title="Request a Service Call" content=$smarty.capture.dialog extra="width=100%"}