
function checkFormC() {

	if(window.document.regC.name.value.length < 3) {
		alert("Please enter your NAME...");
		window.document.regC.name.focus();
		return;
	} else if(window.document.regC.email.value.length < 6) {
		alert("Please enter your EMAIL ADDRESS...");
		window.document.regC.email.focus();
		return;
	} else if(window.document.regC.phone.value.length < 10) {
		alert("Please enter a valid 10-digit PHONE NUMBER...");
		window.document.regC.phone.focus();
		return;
	} else if(window.document.regC.address.value.length < 5) {
		alert("Please enter your ADDRESS...");
		window.document.regC.address.focus();
		return;
	} else if(window.document.regC.city.value.length < 2) {
		alert("Please enter your CITY...");
		window.document.regC.city.focus();
		return;
	
 	} else {
	
		window.document.regC.submit();
	
	}
}

document.write("<left><form name='regC' onSubmit='return false' method=\"post\" action=\"regC.php\"><table><tr><td colspan=2><left><DIV align=left><FONT face=Arial color=#666666 size=2>If you would like to find out more about our products, please fill out the form below.</FONT></DIV><DIV align=left>&nbsp;</DIV></left></td></tr><tr><td colspan=\"2\" align=\"left\"><b>I am a(n):</b></td></tr><tr><td colspan=\"2\">&nbsp; &nbsp; <input type=\"radio\" name=\"custtype\" value=\"Doctor (New Customer)\" CHECKED> Physician (New Customer)</td></tr><tr><td colspan=\"2\">&nbsp; &nbsp; <input type=\"radio\" name=\"custtype\" value=\"Existing Axiom Customer\" CHECKED> Technical Support</td></tr><tr><td colspan=\"2\">&nbsp; &nbsp;<input type=\"radio\" name=\"custtype\" value=\"Existing Axiom Customer\"> Existing Axiom Customer</td></tr><tr><td colspan=\"2\">&nbsp; &nbsp; <input type=\"radio\" name=\"custtype\" value=\"International Distributor\"> International Distributor</td></tr><tr><td colspan=\"2\">&nbsp; &nbsp; <input type=\"radio\" name=\"custtype\" value=\"DRX9000 Patient\"> DRX9000 Patient</td></tr><tr><td></br><b>Name:</b></td><td></br><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td><b>Email:</b></td><td><input type=\"text\" name=\"email\" value=\"\" size=\"20\"></td></tr><tr><td><b>Telephone:</b></td><td><input type=\"text\" name=\"phone\" value=\"\" size=\"20\"></td></tr><tr><td><b>Address:</b></td><td><input type=\"text\" name=\"address\" value=\"\" size=\"20\"></td></tr><tr><td><b>City:</b></td><td><input type=\"text\" name=\"city\" value=\"\" size=\"20\"></td></tr><tr><td><b>State:</b></td><td><select name=\"state\"><option value=\"0\"> </option><option value=\"AK\">AK</option><option value=\"AL\">AL</option><option value=\"AR\">AR</option><option value=\"AZ\">AZ</option><option value=\"CA\">CA</option><option value=\"CO\">CO</option><option value=\"CT\">CT</option><option value=\"DC\">DC</option><option value=\"DE\">DE</option><option value=\"FL\">FL</option><option value=\"GA\">GA</option><option value=\"HI\">HI</option><option value=\"ID\">ID</option><option value=\"IL\">IL</option><option value=\"IN\">IN</option><option value=\"IA\">IA</option><option value=\"KS\">KS</option><option value=\"KY\">KY</option><option value=\"LA\">LA</option><option value=\"ME\">ME</option><option value=\"MD\">MD</option><option value=\"MA\">MA</option><option value=\"MI\">MI</option><option value=\"MN\">MN</option><option value=\"MS\">MS</option><option value=\"MO\">MO</option><option value=\"MT\">MT</option><option value=\"NE\">NE</option><option value=\"NV\">NV</option><option value=\"NH\">NH</option><option value=\"NJ\">NJ</option><option value=\"NM\">NM</option><option value=\"NY\">NY</option><option value=\"NC\">NC</option><option value=\"ND\">ND</option><option value=\"OH\">OH</option><option value=\"OK\">OK</option><option value=\"OR\">OR</option><option value=\"PA\">PA</option><option value=\"PR\">PR</option><option value=\"RI\">RI</option><option value=\"SC\">SC</option><option value=\"SD\">SD</option><option value=\"TN\">TN</option><option value=\"TX\">TX</option><option value=\"UT\">UT</option><option value=\"VT\">VT</option><option value=\"VA\">VA</option><option value=\"WA\">WA</option><option value=\"WV\">WV</option><option value=\"WI\">WI</option><option value=\"WY\">WY</option></select></td></tr><tr><td><b>Zip Code:</b></td><td><input type=\"text\" name=\"zip\" value=\"\" size=\"20\"></td></tr><tr><td><b>Country:</b></td><td><select name=\"country\"><option value=\" \"> </option><option value=\"USA\" selected>USA</option><option value=\"Afghanistan\">Afghanistan</option><option value=\"Albania\">Albania</option><option value=\"Algeria\">Algeria</option><option value=\"Andorra\">Andorra</option><option value=\"Angola\">Angola</option><option value=\"Anguilla\">Anguilla</option><option value=\"Antigua Barbuda\">Antigua Barbuda</option><option value=\"Argentina\">Argentina</option><option value=\"Aruba\">Aruba</option><option value=\"Australia\">Australia</option><option value=\"Austria\">Austria</option><option value=\"Azerbaijan\">Azerbaijan</option><option value=\"Bahamas\">Bahamas</option><option value=\"Bahrain\">Bahrain</option><option value=\"Bangladesh\">Bangladesh</option><option value=\"Barbados\">Barbados</option><option value=\"Belarus\">Belarus</option><option value=\"Belgium\">Belgium</option><option value=\"Belize\">Belize</option><option value=\"Benin\">Benin</option><option value=\"Bermuda\">Bermuda</option><option value=\"Bhutan\">Bhutan</option><option value=\"Bolivia\">Bolivia</option><option value=\"Bosnia-Herzegovina\">Bosnia-Herzegovina</option><option value=\"Botswana\">Botswana</option><option value=\"Brazil\">Brazil</option><option value=\"British Virgin Islands\">British Virgin Islands</option><option value=\"Brunei\">Brunei</option><option value=\"Bulgaria\">Bulgaria</option><option value=\"Burkina\">Burkina</option><option value=\"Burkina Faso\">Burkina Faso</option><option value=\"Burma\">Burma</option><option value=\"Burundi\">Burundi</option><option value=\"Cambodia\">Cambodia</option><option value=\"Cameroon\">Cameroon</option><option value=\"Canada\">Canada</option><option value=\"Cape Verde\">Cape Verde</option><option value=\"Cayman Islands\">Cayman Islands</option><option value=\"Chad\">Chad</option><option value=\"Chile\">Chile</option><option value=\"China\">China</option><option value=\"Colombia\">Colombia</option><option value=\"Comoros\">Comoros</option><option value=\"Congo\">Congo</option><option value=\"Costa Rica\">Costa Rica</option><option value=\"Cote D'Ivoire\">Cote D'Ivoire</option><option value=\"Croatia\">Croatia</option><option value=\"Cuba\">Cuba</option><option value=\"Cyprus\">Cyprus</option><option value=\"Czech Republic\">Czech Republic</option><option value=\"Denmark\">Denmark</option><option value=\"Djibouti\">Djibouti</option><option value=\"Dominica\">Dominica</option><option value=\"Dominican Republic\">Dominican Republic</option><option value=\"Ecuador\">Ecuador</option><option value=\"Egypt\">Egypt</option><option value=\"El Salvador\">El Salvador</option><option value=\"Equatorial Guinea\">Equatorial Guinea</option><option value=\"Eritrea\">Eritrea</option><option value=\"Estonia\">Estonia</option><option value=\"Ethiopia\">Ethiopia</option><option value=\"Falkland Islands\">Falkland Islands</option><option value=\"Faroe Islands\">Faroe Islands</option><option value=\"Fiji\">Fiji</option><option value=\"Finland\">Finland</option><option value=\"France\">France</option><option value=\"French Polynesia\">French Polynesia</option><option value=\"Gabon\">Gabon</option><option value=\"Germany\">Germany</option><option value=\"Ghana\">Ghana</option><option value=\"Gibraltar\">Gibraltar</option><option value=\"Greece\">Greece</option><option value=\"Grenada\">Grenada</option><option value=\"Guam\">Guam</option><option value=\"Guatemala\">Guatemala</option><option value=\"Guinea\">Guinea</option><option value=\"Guinea-Bissau\">Guinea-Bissau</option><option value=\"Guyana\">Guyana</option><option value=\"Haiti\">Haiti</option><option value=\"Honduras\">Honduras</option><option value=\"Hong Kong\">Hong Kong</option><option value=\"Hungary\">Hungary</option><option value=\"Iceland\">Iceland</option><option value=\"India\">India</option><option value=\"Indonesia\">Indonesia</option><option value=\"Iran\">Iran</option><option value=\"Iraq\">Iraq</option><option value=\"Ireland\">Ireland</option><option value=\"Israel\">Israel</option><option value=\"Italy\">Italy</option><option value=\"Jamaica\">Jamaica</option><option value=\"Japan\">Japan</option><option value=\"Jordan\">Jordan</option><option value=\"Kazakstan\">Kazakstan</option><option value=\"Kenya\">Kenya</option><option value=\"Kiribati\">Kiribati</option><option value=\"Kuwait\">Kuwait</option><option value=\"Kyrgyzstan\">Kyrgyzstan</option><option value=\"Laos\">Laos</option><option value=\"Latvia\">Latvia</option><option value=\"Lebanon\">Lebanon</option><option value=\"Lesotho\">Lesotho</option><option value=\"Liberia\">Liberia</option><option value=\"Libya\">Libya</option><option value=\"Liechtenstein\">Liechtenstein</option><option value=\"Lithuania\">Lithuania</option><option value=\"Luxembourg\">Luxembourg</option><option value=\"Macedonia\">Macedonia</option><option value=\"Madagascar\">Madagascar</option><option value=\"Malawi\">Malawi</option><option value=\"Malaysia\">Malaysia</option><option value=\"Maldives\">Maldives</option><option value=\"Mali\">Mali</option><option value=\"Malta\">Malta</option><option value=\"Marshall Islands\">Marshall Islands</option><option value=\"Mauritania\">Mauritania</option><option value=\"Mauritius\">Mauritius</option><option value=\"Mexico\">Mexico</option><option value=\"Micronesia\">Micronesia</option><option value=\"Monaco\">Monaco</option><option value=\"Mongolia\">Mongolia</option><option value=\"Montenegro\">Montenegro</option><option value=\"Montserrat\">Montserrat</option><option value=\"Morocco\">Morocco</option><option value=\"Mozambique\">Mozambique</option><option value=\"Namibia\">Namibia</option><option value=\"Nauru\">Nauru</option><option value=\"Nepal\">Nepal</option><option value=\"Netherlands\">Netherlands</option><option value=\"Netherlands Antilles\">Netherlands Antilles</option><option value=\"New Zealand\">New Zealand</option><option value=\"Nicaragua\">Nicaragua</option><option value=\"Niger\">Niger</option><option value=\"Nigeria\">Nigeria</option><option value=\"North Korea\">North Korea</option><option value=\"Northern Mariana Islands\">Northern Mariana Islands</option><option value=\"Norway\">Norway</option><option value=\"Oman\">Oman</option><option value=\"Pakistan\">Pakistan</option><option value=\"Palua\">Palua</option><option value=\"Panama\">Panama</option><option value=\"Papua New Guinea\">Papua New Guinea</option><option value=\"Paraguay\">Paraguay</option><option value=\"Peru\">Peru</option><option value=\"Philippines\">Philippines</option><option value=\"Pitcairn Island\">Pitcairn Island</option><option value=\"Poland\">Poland</option><option value=\"Portugal\">Portugal</option><option value=\"Puerto Rico\">Puerto Rico</option><option value=\"Qatar\">Qatar</option><option value=\"Romania\">Romania</option><option value=\"Russia\">Russia</option><option value=\"Rwanda\">Rwanda</option><option value=\"Samoa\">Samoa</option><option value=\"San Marino\">San Marino</option><option value=\"Sao Tome and Principe\">Sao Tome and Principe</option><option value=\"Saudi Arabia\">Saudi Arabia</option><option value=\"Senegal\">Senegal</option><option value=\"Serbia\">Serbia</option><option value=\"Seychelles\">Seychelles</option><option value=\"Sierra Leone\">Sierra Leone</option><option value=\"Singapore\">Singapore</option><option value=\"Slovakia\">Slovakia</option><option value=\"Slovenia\">Slovenia</option><option value=\"Solomon Islands\">Solomon Islands</option><option value=\"Somalia\">Somalia</option><option value=\"South Africa\">South Africa</option><option value=\"South Georgia\">South Georgia</option><option value=\"South Korea\">South Korea</option><option value=\"Spain\">Spain</option><option value=\"Sri Lanka\">Sri Lanka</option><option value=\"St Helena\">St Helena</option><option value=\"St Kitts Nevis\">St Kitts Nevis</option><option value=\"St Lucia\">St Lucia</option><option value=\"St Vincent The Grenadines\">St Vincent The Grenadines</option><option value=\"Sudan\">Sudan</option><option value=\"Suriname\">Suriname</option><option value=\"Swaziland\">Swaziland</option><option value=\"Sweden\">Sweden</option><option value=\"Switzerland\">Switzerland</option><option value=\"Syria\">Syria</option><option value=\"Taiwan\">Taiwan</option><option value=\"Tanzania\">Tanzania</option><option value=\"Thailand\">Thailand</option><option value=\"The Gambia\">The Gambia</option><option value=\"Togo\">Togo</option><option value=\"Tonga\">Tonga</option><option value=\"Trinidad and Tobago\">Trinidad and Tobago</option><option value=\"Tunisia\">Tunisia</option><option value=\"Turkey\">Turkey</option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands</option><option value=\"Tuvalu\">Tuvalu</option><option value=\"Uganda\">Uganda</option><option value=\"Ukraine\">Ukraine</option><option value=\"United Arab Emirates\">United Arab Emirates</option><option value=\"United Kingdom\">United Kingdom</option><option value=\"Uruguay\">Uruguay</option><option value=\"Uzbekistan\">Uzbekistan</option><option value=\"Vanuatu\">Vanuatu</option><option value=\"Vatican City State\">Vatican City State</option><option value=\"Venezuela\">Venezuela</option><option value=\"Vietnam\">Vietnam</option><option value=\"West Indies\">West Indies</option><option value=\"Western Samoa\">Western Samoa</option><option value=\"Yemen\">Yemen</option><option value=\"Zambia\">Zambia</option><option value=\"Zimbabwe\">Zimbabwe</option></select></td></tr><tr><td align=\"center\" colspan=\"2\"><br><b>Comments/Questions:</b><br><textarea name='comments' rows='9' style='width: 240px;' wrap='soft'></textarea><br><br><input type=\"button\" name=\"submitC\" value=\"Submit\" onClick='checkFormC();'></td></tr></table></form></center>");



