document.write("<script language=\"Javascript\">function radioSelected(radio){result = false;for (var i=0; i<radio.length; i++){if(radio[i].checked){result = true;}}return result;}function checkVCSForm(){ if (!document.vcsform.fullname.value){alert('Please enter your name');return false;}if (!document.vcsform.email.value){alert('Please enter your email address');return false;}if (!document.vcsform.phone_number.value){alert('Please enter your phone number');return false;}if (!radioSelected(document.vcsform.problem)){alert('Please select a problem type');return false;}return true;}function send(){if(checkVCSForm()){alert('Thank you! Your information has been sent to our Customer Service Manager for review.');document.vcsform.submit()}}</script>");

document.write('<div id="vcsform"><form id="vcsform" name="vcsform" method="post" action="http://vwdhost.com/customerservice/scribblinsisters/formprocess.php"><p><label for="fullname">Full Name:</label><input class="itext" type="text" name="fullname" value="" /></p><p><label for="email">Email:</label><input class="itext" type="text" name="email" value="" /></p><p><label for="order_number">Order Number:</label><input class="itext" type="text" name="order_number" value="" /></p><p><label for="phone_number">Phone Number:</label><input class="itext" type="text" name="phone_number" value="" /></p><p><label for="problem" style="width:135px;">Type of Problem:</label></p><table width="300" border="0" cellspacing="0" cellpadding="0"><tr><td><p><input name="problem" class="iradio" type="radio" value="1"><span class="text">I never received my order</span></p></td></tr><tr><td><p><input name="problem" class="iradio" type="radio" value="2"><span class="text">Items are missing from my order</span></p></td></tr><tr><td><p><input name="problem" class="iradio" type="radio" value="3"><span class="text">I received the wrong order</span></p></td></tr><tr><td><p><input name="problem" class="iradio" type="radio" value="4"><span class="text">My items are damaged</span></p></td></tr><tr><td><p><input name="problem" class="iradio" type="radio" value="5"><span class="text">My credit card was charged incorrectly</span></p></td></tr><tr><td><p><input name="problem" class="iradio" type="radio" value="6"><span class="text">Other</span></p></td></tr></table><p><label for="item_list">*If you are reporting damaged or missing items, please list them here:</label><textarea name="item_list"></textarea></p><p><label for="comments">Comments / Questions / Suggestions:</label><textarea name="comments"></textarea></p><p><label>&nbsp;</label><a href="javascript:send()" class="button">Submit</a></span><input name="process" type="hidden" value="1" /></p></form></div>');