<?php
require_once("includes/config.php");
$companyName = empty($_COOKIE['company']) ? "Required" : $_COOKIE['company'];

?>
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<head>
<title>Support Request Form - Touch Portal - Cervion Systems</title>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
<meta name="robots" content="noindex, nofollow" />
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</head>
<body>
<table width="924" border="0" align="center" cellpadding="0" cellspacing="0">
  <tr>
    <td height="70" valign="top"><img src="images/first_header.png" width="924" height="44" alt="Support Request Form" /></td>
  </tr>
  <tr>
    <td height="485" valign="middle">
	<div id="order_form_content">
		<div id="contact_form">
			<form method="post" action="issue.php" id="first_form">
			<div class="contact_text">YOUR NAME</div><div><input type="text" name="name" class="input_form" id="name" value="Required" /></div>
			
			<div class="contact_text">YOUR COMPANY</div><div><input type="text" name="company" class="input_form" id="company" value="<?php echo htmlspecialchars($companyName,ENT_QUOTES); ?>" /></div>
			<br clear="both" />
			<div id="post_form_first_page">
				<div id="support_info">Portal support requests are monitored during business hours.<br />For emergency support, please call (877) 476-7246, option #2.</div>
                <div id="next"></div>
				<div id="back"></div>
				<br clear="both" />
				<div id="errors"><span style="color:red;">ERROR:</span><span id="errors_info"></span></div>
			</div>
			<br clear="both" />
			</form>
		</div>
		
<div id="keyboardContainer">
	<ul class="keyboard row1">
		<li class="symbol"><span class="off">`</span><span class="on">~</span></li>
		<li class="symbol"><span class="off">1</span><span class="on">!</span></li>
		<li class="symbol"><span class="off">2</span><span class="on">@</span></li>
		<li class="symbol"><span class="off">3</span><span class="on">#</span></li>
		<li class="symbol"><span class="off">4</span><span class="on">$</span></li>
		<li class="symbol"><span class="off">5</span><span class="on">%</span></li>
		<li class="symbol"><span class="off">6</span><span class="on">^</span></li>
		<li class="symbol"><span class="off">7</span><span class="on">&amp;</span></li>
		<li class="symbol"><span class="off">8</span><span class="on">*</span></li>
		<li class="symbol"><span class="off">9</span><span class="on">(</span></li>
		<li class="symbol"><span class="off">0</span><span class="on">)</span></li>
		<li class="symbol"><span class="off">-</span><span class="on">_</span></li>
		<li class="symbol"><span class="off">=</span><span class="on">+</span></li>
		<li class="delete lastitem">DEL</li>
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		<li class="tab">TAB</li>
		<li class="letter">q</li>
		<li class="letter">w</li>
		<li class="letter">e</li>
		<li class="letter">r</li>
		<li class="letter">t</li>
		<li class="letter">y</li>
		<li class="letter">u</li>
		<li class="letter">i</li>
		<li class="letter">o</li>
		<li class="letter">p</li>
		<li class="symbol"><span class="off">[</span><span class="on">{</span></li>
		<li class="symbol"><span class="off">]</span><span class="on">}</span></li>
		<li class="symbol lastitem"><span class="off">\</span><span class="on">|</span></li>
	</ul>
	<ul class="keyboard row3">
		<li class="capslock">CAPS</li>
		<li class="letter">a</li>
		<li class="letter">s</li>
		<li class="letter">d</li>
		<li class="letter">f</li>
		<li class="letter">g</li>
		<li class="letter">h</li>
		<li class="letter">j</li>
		<li class="letter">k</li>
		<li class="letter">l</li>
		<li class="symbol"><span class="off">;</span><span class="on">:</span></li>
		<li class="symbol"><span class="off">'</span><span class="on">&quot;</span></li>
		<li class="return lastitem">RET</li>
		
	</ul>
	<ul class="keyboard row4">
		<li class="left-shift">SHIFT</li>
		<li class="letter">z</li>
		<li class="letter">x</li>
		<li class="letter">c</li>
		<li class="letter">v</li>
		<li class="letter">b</li>
		<li class="letter">n</li>
		<li class="letter">m</li>
		<li class="symbol"><span class="off">,</span><span class="on">&lt;</span></li>
		<li class="symbol"><span class="off">.</span><span class="on">&gt;</span></li>
		<li class="symbol"><span class="off">/</span><span class="on">?</span></li>
		<li class="right-shift lastitem">SHIFT</li>
		<li class="space lastitem">SPACE</li>
	</ul>
</div>
<br clear="both" />
		
		
	</div>
</div>
    </td>
  </tr>
  <tr>
    <td height="40" valign="bottom"><img src="images/footer.png" width="924" height="10" alt="Cervion Systems - (877) 476-7246" /></td>
  </tr>
</table>
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