document.write("<title>Rockback ECS Puppies</title>\n");
document.write("<scr"+"ipt language=javascr"+"ipt>\n");
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document.write("<form  method=POST action=\"https://rockbackecs.com/cgi-scr"+"ipt/csFormbuilder/csFormbuilder.cgi\" name=\"form_5\"  >\n");
document.write("<input type=hidden name=form-id value=\"5\">\n");
document.write("<input type=hidden name=command value=\"mailform\">\n");
document.write("<link rel=\"stylesheet\" type=\"text/css\" href=\"https://rockbackecs.com/cgi-scr"+"ipt/csFormbuilder/forms/puppies.css\">\n");
document.write("<table border=\"0\" cellspacing=\"0\" cellpadding=\"3\">\n");
document.write("<tr><td class=\"textLabel\" colspan=2><P><FONT face=Verdana size=4><STRONG>Puppy Questionnaire</STRONG></FONT></P></td></tr><tr><td class=\"textLabel\" colspan=2>When you have completed the Questionnaire click the submit button. \"*\" indicates mandatory fields.</td></tr><tr><td class=\"textLabel\" colspan=2><hr width=\"100%\" size=\"1\" color=\"black\" align=\"left\"></td></tr><tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*First Name</td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Name\"  size=\"30\"   maxlength=\"30\" ></td>\n");
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document.write("</table>   <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Last Name</td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"LastName\"  size=\"30\"   maxlength=\"30\" ></td>\n");
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document.write("</table><!-- tr ph 1--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Email</td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email\"  size=\"30\"   maxlength=\"100\" ></td>\n");
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document.write("</table>  <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Verify Email</td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email_Verify\"  size=\"30\"   maxlength=\"100\" ></td>\n");
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document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Phone</td>\n");
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document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone_1\" size=\"3\" maxlength=\"3\"></td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>)</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>&nbsp;</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone_2\" size=\"3\" maxlength=\"3\"></td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>-</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone_3\" size=\"4\" maxlength=\"4\"><input type=hidden name=\"Phone\" value=\"1\"></td>\n");
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document.write("      </table>\n");
document.write("      </td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 3--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Address</td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Address\"  size=\"30\"  ></td>\n");
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document.write("</table>   <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">City</td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"City\"  size=\"15\"  ></td>\n");
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document.write("</table>  <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*State </td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><select name=\"State\"  size=\"1\"   onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\">\n");
document.write("<option value=\"\"></option>\n");
document.write("<option value=\"AK\">AK-Alaska</option>\n");
document.write("<option value=\"AL\">AL-Alabama</option>\n");
document.write("<option value=\"AR\">AR-Arkansas</option>\n");
document.write("<option value=\"AZ\">AZ-Arizona</option>\n");
document.write("<option value=\"CA\">CA-California</option>\n");
document.write("<option value=\"CO\">CO-Colorado</option>\n");
document.write("<option value=\"CT\">CT-Connecticut</option>\n");
document.write("<option value=\"DC\">DC-District of Columbia</option>\n");
document.write("<option value=\"DE\">DE-Delaware</option>\n");
document.write("<option value=\"FL\">FL-Florida</option>\n");
document.write("<option value=\"GA\">GA-Georgia</option>\n");
document.write("<option value=\"HI\">HI-Hawaii</option>\n");
document.write("<option value=\"IA\">IA-Iowa</option>\n");
document.write("<option value=\"ID\">ID-Idaho</option>\n");
document.write("<option value=\"IL\">IL-Illinois</option>\n");
document.write("<option value=\"IN\">IN-Indiana</option>\n");
document.write("<option value=\"KS\">KS-Kansas</option>\n");
document.write("<option value=\"KY\">KY-Kentucky</option>\n");
document.write("<option value=\"LA\">LA-Louisiana</option>\n");
document.write("<option value=\"MA\">MA-Massachusetts</option>\n");
document.write("<option value=\"MD\">MD-Maryland</option>\n");
document.write("<option value=\"ME\">ME-Maine</option>\n");
document.write("<option value=\"MI\">MI-Michigan</option>\n");
document.write("<option value=\"MN\">MN-Minnesota</option>\n");
document.write("<option value=\"MO\">MO-Missouri</option>\n");
document.write("<option value=\"MS\">MS-Mississippi</option>\n");
document.write("<option value=\"MT\">MT-Montana</option>\n");
document.write("<option value=\"NC\">NC-North Carolina</option>\n");
document.write("<option value=\"ND\">ND-North Dakota</option>\n");
document.write("<option value=\"NE\">NE-Nebraska</option>\n");
document.write("<option value=\"NH\">NH-New Hampshire</option>\n");
document.write("<option value=\"NJ\">NJ-New Jersey</option>\n");
document.write("<option value=\"NM\">NM-New Mexico</option>\n");
document.write("<option value=\"NV\">NV-Nevada</option>\n");
document.write("<option value=\"NY\">NY-New York</option>\n");
document.write("<option value=\"OH\">OH-Ohio</option>\n");
document.write("<option value=\"OK\">OK-Oklahoma</option>\n");
document.write("<option value=\"OR\">OR-Oregon</option>\n");
document.write("<option value=\"OT\">OT-Other</option>\n");
document.write("<option value=\"PA\">PA-Pennsylvania</option>\n");
document.write("<option value=\"RI\">RI-Rhode Island</option>\n");
document.write("<option value=\"SC\">SC-South Carolina</option>\n");
document.write("<option value=\"SD\">SD-South Dakota</option>\n");
document.write("<option value=\"TN\">TN-Tennessee</option>\n");
document.write("<option value=\"TX\">TX-Texas</option>\n");
document.write("<option value=\"UT\">UT-Utah</option>\n");
document.write("<option value=\"VA\">VA-Virginia</option>\n");
document.write("<option value=\"VT\">VT-Vermont</option>\n");
document.write("<option value=\"WA\">WA-Washington</option>\n");
document.write("<option value=\"WI\">WI-Wisconsin</option>\n");
document.write("<option value=\"WV\">WV-West Virginia</option>\n");
document.write("<option value=\"WY\">WY-Wyoming</option>\n");
document.write("</select>&nbsp;</td>\n");
document.write("</tr>\n");
document.write("</table><!-- tr ph 6--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*How did you discover our dogs? </td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><select name=\"Discover\"  size=\"1\"   onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\">\n");
document.write("<option value=\"\">-= Select =-</option>\n");
document.write("<option>Web Site</option>\n");
document.write("<option>Dog Show</option>\n");
document.write("<option>AKC</option>\n");
document.write("<option>Friend</option>\n");
document.write("<option>Previous Adoption</option>\n");
document.write("<option>Other</option></select> Other: <input type=text name=\"Discover\"  size=\"50\"   maxlength=\"100\" >\n");
document.write("&nbsp;</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 7--></td></tr>\n");
document.write("<tr><td class=\"textLabel\" colspan=2  height=\"6\" ></td></tr><tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Is this your first English Cocker Spaniel? </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"FirstDog\" value=\"Yes\"></td><td class=\"textLabel\">Yes</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"FirstDog\" value=\"No\"></td><td class=\"textLabel\">No</td>\n");
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document.write("</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 8--></td></tr>\n");
document.write("<tr><td class=\"textLabel\" colspan=2  height=\"6\" ></td></tr><tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*What activities are you interested in for your dog? </td>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Activities\" value=\"Confirmation\"></td><td class=\"textLabel\">Confirmation</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Activities\" value=\"Performance\"></td><td class=\"textLabel\">Performance</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Activities\" value=\"Field Work\"></td><td class=\"textLabel\">Field Work</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Activities\" value=\"Therapy\"></td><td class=\"textLabel\">Therapy</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Activities\" value=\"\"></td><td class=\"textLabel\">Other: <input type=text name=\"Activities\"  size=\"20\"  ></td>\n");
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document.write("</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 9--></td></tr>\n");
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document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Additional Comments</td>\n");
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document.write("</table> <!-- tr ph 10--></td></tr>\n");
document.write("<tr><td colspan=2 align=\"left\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=submit value=\":: Submit ::\"></td></tr>\n");
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