Name: *
E-Mail: *
Phone: *
Company:
Part Number:
Description: *
value="end user">End User value="reseller">Reseller *>
Your Input"; echo $name; echo "
"; echo $email; echo "
"; echo $phone; echo "
"; echo $company; echo "
"; echo $part_number; echo "
"; echo $description; echo "
"; echo $cust_type; ?>