<?php if(!defined('IN_GS')){ die('you cannot load this page directly.'); }?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" 
"http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title><?php get_page_clean_title(); ?> - <?php get_site_name(); ?> - Cervion Systems</title>
<?php get_header(); ?>
<meta name="robots" content="index, follow" />
<link rel="stylesheet" type="text/css" href="<?php get_theme_url(); ?>/includes/style.css" media="all" />
<link href="<?php get_theme_url(); ?>/includes/wufoo/structure.css" rel="stylesheet">
<link href="<?php get_theme_url(); ?>/includes/wufoo/form.css" rel="stylesheet">
<link href="<?php get_theme_url(); ?>/includes/wufoo/theme.css" rel="stylesheet">
<link href="http://links.cervion.com/web/wufoo-custom.css" rel="stylesheet">
<script src="<?php get_theme_url(); ?>/includes/wufoo/wufoo.js"></script>
<link rel="stylesheet" type="text/css" href="<?php get_theme_url(); ?>/includes/tooltip/style.css" media="all" />
<script type="text/javascript" src="<?php get_theme_url(); ?>/includes/tooltip/tooltip.js"></script>
</head>

<body id="<?php get_page_slug(); ?>" >
<div id="header">
  <table width="980" border="0" align="center" cellpadding="0" cellspacing="0">
    <tr>
      <td height="135" valign="top" id="header-box"><table width="936" border="0" align="center" cellpadding="0" cellspacing="0">
        <tr>
          <td align="right"><table width="180" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td align="center" id="header-nav" class="nav-header"><a href="http://tp.cervion.com/">Touch Portal Access</a></td>
            </tr>
          </table></td>
        </tr>
      </table>
        <img src="<?php get_theme_url(); ?>/images/logo.png" alt="Cervion Systems - Customer Portal" width="325" height="72" border="0" align="left" /> <img src="<?php get_theme_url(); ?>/images/contact.png" alt="877-476-7246" width="161" height="76" border="0" align="right" /></td>
    </tr>
    <tr>
      <td height="34"><table width="936" border="0" align="center" cellpadding="0" cellspacing="0">
        <tr>
          <td width="852" align="left" class="nav" id="nav-box"><a href="http://customer.cervion.com/">Home</a> <a href="/support/options/">Support Info</a> <a href="/resources/">Customer Resources</a> <a href="http://www.cervion.com/">Cervion.com</a></td>
          <td width="84"><table width="84" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td width="18"><a href="http://www.facebook.com/cervion" target="_blank"> <img src="<?php get_theme_url(); ?>/images/social/facebook-icon.png" alt="Facebook" width="18" height="18" border="0" /></a></td>
              <td width="4">&nbsp;</td>
              <td width="18"><a href="http://www.twitter.com/cervion" target="_blank"> <img src="<?php get_theme_url(); ?>/images/social/twitter-icon.png" alt="Twitter" width="18" height="18" border="0" /></a></td>
              <td width="4">&nbsp;</td>
              <td width="18"><a href="http://www.linkedin.com/pub/hunter-allen/4/5a5/815" target="_blank"> <img src="<?php get_theme_url(); ?>/images/social/linkedin-icon.png" alt="LinkedIn" width="18" height="18" border="0" /></a></td>
              <td width="4">&nbsp;</td>
              <td width="18"><img src="<?php get_theme_url(); ?>/images/social/email-icon.png" alt="Email" width="18" height="18" border="0" /></td>
            </tr>
          </table></td>
        </tr>
      </table></td>
    </tr>
  </table>
</div>
<div id="body-bg">
  <table width="980" border="0" align="center" cellpadding="0" cellspacing="0">
    <tr>
      <td height="22">&nbsp;</td>
    </tr>
    <tr>
      <td valign="top"><table width="936" border="0" align="center" cellpadding="0" cellspacing="0">
        <tr>
          <td width="301" valign="top"><table width="301" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td><img src="<?php get_theme_url(); ?>/images/boxes/subnav-top.png" width="301" height="22" /></td>
            </tr>
            <tr>
              <td valign="top" id="subnav-box"><table width="257" border="0" align="center" cellpadding="0" cellspacing="0">
                <tr>
                  <td class="subnav-spacer"><a href="/support/">
                  <img src="<?php get_theme_url(); ?>/images/buttons/support-request.png" alt="Support Request" width="257" height="50" border="0" /></a></td>
                </tr>
                <tr>
                  <td class="subnav-spacer"><a href="/order-supplies-form/">
                  <img src="<?php get_theme_url(); ?>/images/buttons/order-supplies.png" alt="Order Supplies" width="257" height="50" border="0" /></a></td>
                </tr>
                <tr>
                  <td class="subnav-spacer"><a href="/resources/training-videos">
                  <img src="<?php get_theme_url(); ?>/images/buttons/training-videos.png" alt="Training Videos" width="257" height="50" border="0" /></a></td>
                </tr>
                <tr>
                  <td class="subnav-spacer"><a href="/resources/">
                  <img src="<?php get_theme_url(); ?>/images/buttons/resources.png" alt="Customer Forms & Links" width="257" height="50" border="0" /></a></td>
                </tr>
                <tr>
                  <td class="subnav-spacer"><a href="/products/">
                  <img src="<?php get_theme_url(); ?>/images/buttons/product-addons.png" alt="Additional Products" width="257" height="50" border="0"  /></a></td>
                </tr>
                  <td height="117" align="center"><img src="<?php get_theme_url(); ?>/images/buttons/email-list.png" alt="Email Archive" width="257" height="117" border="0" /></td>
                </tr>
                <tr>
                  <td align="left">
                  <?php include('includes/wufoo/form.php'); ?>
                  </td>
                </tr>
                <tr>
                  <td height="25" align="left">&nbsp;</td>
                </tr>
                <tr>
                  <td class="social-spacer">
                  <a href="http://www.facebook.com/cervion" target="_blank">
                  <img src="<?php get_theme_url(); ?>/images/social/facebook-button.png" alt="Cervion on Facebook" width="257" height="43" border="0" />
                  </a></td>
                </tr>
                <tr>
                  <td class="social-spacer"><a href="http://www.twitter.com/cervion" target="_blank">
                  <img src="<?php get_theme_url(); ?>/images/social/twitter-button.png" alt="Cervion Twitter" width="257" height="43" border="0" />
                  </a></td>
                </tr>
                </table></td>
            </tr>
            <tr>
              <td><img src="<?php get_theme_url(); ?>/images/boxes/subnav-bottom.png" width="301" height="22" /></td>
            </tr>
          </table></td>
          <td width="22">&nbsp;</td>
          <td width="613" valign="top"><table width="613" border="0" align="center" cellpadding="0" cellspacing="0">
            <tr>
              <td><table width="613" border="0" cellspacing="0" cellpadding="0">
                <tr>
                  <td><img src="<?php get_theme_url(); ?>/images/boxes/news-top.png" alt="" width="613" height="22" /></td>
                </tr>
                <tr>
                  <td id="news-box"><table width="569" border="0" align="center" cellpadding="0" cellspacing="0">
                    <tr>
                      <td align="left" valign="top">
                      <table width="569" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <td><h1>Supply Order Form</h1></td>
  </tr>
  <tr>
    <td class="content">Please use this form to order POS supplies - paper, ribbon and manager swipe cards.<br />
      <em>We require that all fields on this form be completed before submission.</em></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td class="content"><form action="/theme/Cervion/includes/forms/supply-form.php" method="post">
      <table width="300" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td>Business Name:</td>
        </tr>
        <tr>
          <td><input name="business" type="text" size="40" /></td>
        </tr>
        </table>
        <br />
      <hr style="border-top:1px dashed;" />
      <h3>Contact Information</h3>
      <table width="540" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td width="265">First Name:</td>
          <td width="10">&nbsp;</td>
          <td width="265">Last Name:</td>
        </tr>
        <tr>
          <td><input name="firstname" type="text" size="30" /></td>
          <td>&nbsp;</td>
          <td><input name="lastname" type="text" size="30" /></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td>Email Address:</td>
          <td>&nbsp;</td>
          <td>Phone Number:</td>
        </tr>
        <tr>
          <td><input name="email" type="text" size="30" /></td>
          <td>&nbsp;</td>
          <td><input name="phone" type="text" size="30" /></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td>Should we contact you before shipping?</td>
          <td>&nbsp;</td>
          <td>
            <input type="radio" name="contact" value="Yes" />Yes 
            <input type="radio" name="contact" value="No" />No
            </td>
        </tr>
        </table>
      <br />
      <hr style="border-top:1px dashed;" />
      <h3>Available Products</h3>
      Please enter the quantity of boxes you'd like to order per item.
      <br />
      <em>Invoices  processed per the account terms and shipped to the address on file.<br />
      <br />
      </em>
      <table width="569" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td colspan="2"><strong><u>ITEM &amp; DESCRIPTION</u></strong></td>
          <td width="259"><strong><u>QTY</u></strong></td>
        </tr>
        <tr>
          <td width="10">&nbsp;</td>
          <td width="300">&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td bgcolor="#eeeeee">&nbsp;</td>
          <td height="60" bgcolor="#eeeeee">3 1/8&rdquo; Thermal Paper - $89.00<br />
            <em>Guest check paper - 50 rolls</em></td>
          <td bgcolor="#eeeeee">
            <select name="product1">
              <option value="">0</option>
              <option>1</option>
              <option>2</option>
              <option>3</option>
              <option>4</option>
              <option>5</option>
              <option>6</option>
              <option>7</option>
              <option>8</option>
              <option>9</option>
              <option>10</option>
              </select>
          </td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td bgcolor="#eeeeee">&nbsp;</td>
          <td height="60" bgcolor="#eeeeee">3&rdquo; One Ply Paper - $39.00<br />
            <em>Kitchen printer paper (White) - 50 rolls</em></td>
          <td bgcolor="#eeeeee"><select name="product2">
            <option value="">0</option>
            <option>1</option>
            <option>2</option>
            <option>3</option>
            <option>4</option>
            <option>5</option>
            <option>6</option>
            <option>7</option>
            <option>8</option>
            <option>9</option>
            <option>10</option>
          </select></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td bgcolor="#eeeeee">&nbsp;</td>
          <td height="60" bgcolor="#eeeeee">3&rdquo; Two Ply Paper - $63.00<br />
            <em>Kitchen printer paper (W/Y) - 50 rolls</em></td>
          <td bgcolor="#eeeeee"><select name="product3">
            <option value="">0</option>
            <option>1</option>
            <option>2</option>
            <option>3</option>
            <option>4</option>
            <option>5</option>
            <option>6</option>
            <option>7</option>
            <option>8</option>
            <option>9</option>
            <option>10</option>
          </select></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td bgcolor="#eeeeee">&nbsp;</td>
          <td height="60" bgcolor="#eeeeee">3&rdquo; Three Ply Paper - $89.00<br />
            <em>Kitchen printer paper (W/Y/P) - 50 rolls</em></td>
          <td bgcolor="#eeeeee"><select name="product4">
            <option value="">0</option>
            <option>1</option>
            <option>2</option>
            <option>3</option>
            <option>4</option>
            <option>5</option>
            <option>6</option>
            <option>7</option>
            <option>8</option>
            <option>9</option>
            <option>10</option>
          </select></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td bgcolor="#eeeeee">&nbsp;</td>
          <td height="60" bgcolor="#eeeeee">Remote Printer Ribbons - $24.00<br />
            <em>Black/Red - 1 dozen</em></td>
          <td bgcolor="#eeeeee"><select name="product5">
            <option value="">0</option>
            <option>1</option>
            <option>2</option>
            <option>3</option>
            <option>4</option>
            <option>5</option>
            <option>6</option>
            <option>7</option>
            <option>8</option>
            <option>9</option>
            <option>10</option>
          </select></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td bgcolor="#eeeeee">&nbsp;</td>
          <td height="60" bgcolor="#eeeeee">Manager Swipe Cards - $2.00 (each)<br />
            <em>Swipe cards for system access</em></td>
          <td bgcolor="#eeeeee"><select name="product6">
            <option value="">0</option>
            <option>1</option>
            <option>2</option>
            <option>3</option>
            <option>4</option>
            <option>5</option>
            <option>6</option>
            <option>7</option>
            <option>8</option>
            <option>9</option>
            <option>10</option>
            </select></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td height="40">&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td><table width="259" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td align="right">Promo Code:</td>
            </tr>
            <tr>
              <td align="right"><input name="promocode" type="text" size="30" /></td>
            </tr>
          </table></td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td height="30">&nbsp;</td>
          <td>&nbsp;</td>
        </tr>
        <tr>
          <td>&nbsp;</td>
          <td>&nbsp;</td>
          <td align="right"><input type="image" src="http://links.cervion.com/web/wufoo-order.png" value="Place Order" />
          <br /><br />
          </td>
        </tr>
        </table>
    </form></td>
  </tr>
</table>
                      </td>
                    </tr>
                  </table></td>
                </tr>
                <tr>
                  <td><img src="<?php get_theme_url(); ?>/images/boxes/news-bottom.png" alt="" width="613" height="22" /></td>
                </tr>
              </table></td>
            </tr>
            </table></td>
        </tr>
      </table></td>
    </tr>
    <tr>
      <td height="43">&nbsp;</td>
    </tr>
  </table>
</div>
<div id="footer-line"></div>
<div id="footer">
	<span class="footer-nav">Home | Training &amp; Support | Forms &amp; Resources |  Cervion.com
    </span><br />
	<span class="copyright">&copy; 2013 Cervion Systems. All Rights Reserved.
</span></div>
<?php get_component('analytics'); ?>
<?php get_footer(); ?>
</body>
</html>
