var mylocation = window.location;
var sitename='IndiaEdu.com';
var siteURL='www.indiaedu.com';
//var siteURL='172.16.1.231';
//var siteURL='localhost/indiaedu.com';




var cntdis = '<option value="Afghanistan">Afghanistan <option value="Albania">Albania <option value="Algeria">Algeria <option value="American Samoa">American Samoa <option value="Andorra">Andorra <option value="Angola">Angola <option value="Anguilla">Anguilla <option value="Anguilla">Antarctica <option value="Antigua and Barbuda">Antigua and Barbuda <option value="Argentina">Argentina <option value="Armenia">Armenia <option value="Aruba">Aruba <option value="Australia">Australia <option value="Austria">Austria <option value="Azerbaijan">Azerbaijan <option value="Bahamas">Bahamas <option value="Bahrain">Bahrain <option value="Bangladesh">Bangladesh <option value="Barbados">Barbados <option value="Belarus">Belarus <option value="Belgium">Belgium <option value="Belize">Belize <option value="Benin">Benin <option value="Bermuda">Bermuda <option value="Bhutan">Bhutan <option value="Bolivia">Bolivia <option value="Bosnia and Herzegovina">Bosnia &amp; Herzegovina <option value="Botswana">Botswana <option value="Brazil">Brazil <option value="British Indian Ocean Territory">British Indian Ocean <option value="British Virgin Islands">British Virgin Islands <option value="Brunei">Brunei <option value="Bulgaria">Bulgaria <option value="Burkina Faso">Burkina Faso <option value="Burundi">Burundi <option value="Cambodia">Cambodia <option value="Cameroon">Cameroon <option value="Canada">Canada <option value="Cape Verde">Cape Verde <option value="Cayman Islands">Cayman Islands <option value="Central African Republic">Central African Rep. <option value="Chad">Chad <option value="Chile">Chile <option value="China">China <option value="Christmas Island">Christmas Island <option value="Cocos Islands">Cocos Islands <option value="Colombia">Colombia <option value="Comoros">Comoros <option value="Congo">Congo <option value="Cook Islands">Cook Islands <option value="Costa Rica">Costa Rica <option value="Croatia">Croatia <option value="Cuba">Cuba <option value="Cyprus">Cyprus <option value="Czech Republic">Czech Republic <option value="Denmark">Denmark <option value="Djibouti">Djibouti <option value="Dominica">Dominica <option value="Dominican Republic">Dominican Republic <option value="East Timor">East Timor <option value="Ecuador">Ecuador <option value="Egypt">Egypt <option value="El Salvador">El Salvador <option value="Equatorial Guinea">Equatorial Guinea <option value="Eritrea">Eritrea <option value="Estonia">Estonia <option value="Ethiopia">Ethiopia <option value="Falkland Islands">Falkland Islands <option value="Faroe Islands">Faroe Islands <option value="Fiji">Fiji <option value="Finland">Finland <option value="France">France <option value="French Guiana">French Guiana <option value="French Polynesia">French Polynesia <option value="French Southern Territories">French Southern Terr. <option value="Gabon">Gabon <option value="Gambia">Gambia <option value="Georgia">Georgia <option value="Germany">Germany <option value="Ghana">Ghana <option value="Gibraltar">Gibraltar <option value="Greece">Greece <option value="Greenland">Greenland <option value="Grenada">Grenada <option value="Guadeloupe">Guadeloupe <option value="Guam">Guam <option value="Guatemala">Guatemala <option value="Guinea">Guinea <option value="Guinea-Bissau">Guinea-Bissau <option value="Guyana">Guyana <option value="Haiti">Haiti <option value="Heard and McDonald Islands">Heard &amp; McDonald <option value="Honduras">Honduras <option value="Hong Kong">Hong Kong <option value="Hungary">Hungary <option value="Iceland">Iceland <option value="India">India <option value="Indonesia">Indonesia <option value="Iran">Iran <option value="Iraq">Iraq <option value="Ireland">Ireland <option value="Israel">Israel <option value="Italy">Italy <option value="Ivory Coast">Ivory Coast <option value="Jamaica">Jamaica <option value="Japan">Japan <option value="Jordan">Jordan <option value="Kazakhstan">Kazakhstan <option value="Kenya">Kenya <option value="Kiribati">Kiribati <option value="Korea, North">Korea, North <option value="Korea, South">Korea, South <option value="Kuwait">Kuwait <option value="Kyrgyzstan">Kyrgyzstan <option value="Laos">Laos <option value="Latvia">Latvia <option value="Lebanon">Lebanon <option value="Lesotho">Lesotho <option value="Liberia">Liberia <option value="Libya">Libya <option value="Liechtenstein">Liechtenstein <option value="Lithuania">Lithuania <option value="Luxembourg">Luxembourg <option value="Macau">Macau <option value="Madagascar">Madagascar <option value="Malawi">Malawi <option value="Malaysia">Malaysia <option value="Maldives">Maldives <option value="Mali">Mali <option value="Malta">Malta <option value="Marshall Islands">Marshall Islands <option value="Martinique">Martinique <option value="Mauritania">Mauritania <option value="Mauritius">Mauritius <option value="Mayotte">Mayotte <option value="Mexico">Mexico <option value="Micronesia, Federated States of">Micronesia, Fed. St. <option value="Moldova">Moldova <option value="Monaco">Monaco <option value="Mongolia">Mongolia <option value="Montserrat">Montserrat <option value="Morocco">Morocco <option value="Mozambique">Mozambique <option value="Myanmar">Myanmar <option value="Namibia">Namibia <option value="Nauru">Nauru <option value="Nepal">Nepal <option value="Netherlands">Netherlands <option value="Netherlands Antilles">Netherlands Antilles <option value="New Caledonia">New Caledonia <option value="New Zealand">New Zealand <option value="Nicaragua">Nicaragua <option value="Niger">Niger <option value="Nigeria">Nigeria <option value="Niue">Niue <option value="Norfolk Island">Norfolk Island <option value="Northern Mariana Islands">Northern Mariana Isl. <option value="Norway">Norway <option value="Oman">Oman <option value="Pakistan">Pakistan <option value="Palau">Palau <option value="Panama">Panama <option value="Papua New Guinea">Papua New Guinea <option value="Paraguay">Paraguay <option value="Peru">Peru <option value="Philippines">Philippines <option value="Pitcairn Island">Pitcairn Island <option value="Poland">Poland <option value="Portugal">Portugal <option value="Puerto Rico">Puerto Rico <option value="Qatar">Qatar <option value="Reunion">Reunion <option value="Romania">Romania <option value="Russia">Russia <option value="Rwanda">Rwanda <option value="S. Georgia and S. Sandwich Isls.">S.Georgia &amp; S.Sand. <option value="Saint Kitts &amp; Nevis">Saint Kitts &amp; Nevis <option value="Saint Lucia">Saint Lucia <option value="Saint Vincent and The Grenadines">St.Vincent &amp; Gren. <option value="Samoa">Samoa <option value="San Marino">San Marino <option value="Sao Tome and Principe">Sao Tome &amp; Principe <option value="Saudi Arabia">Saudi Arabia <option value="Senegal">Senegal <option value="Seychelles">Seychelles <option value="Seychelles">Seychelles <option value="Singapore">Singapore <option value="Slovakia">Slovakia <option value="Slovenia">Slovenia <option value="Somalia">Somalia <option value="South Africa">South Africa <option value="Spain">Spain <option value="Sri Lanka">Sri Lanka <option value="St. Helena">St. Helena <option value="St. Pierre and Miquelon">St. Pierre &amp; Miquelon <option value="Sudan">Sudan <option value="Suriname">Suriname <option value="Svalbard and Jan Mayen Islands">Svalbard &amp; J.Mayen <option value="Swaziland">Swaziland <option value="Sweden">Sweden <option value="Switzerland">Switzerland <option value="Syria">Syria <option value="Taiwan">Taiwan <option value="Tajikistan">Tajikistan <option value="Tanzania">Tanzania <option value="Thailand">Thailand <option value="Togo">Togo <option value="Tokelau">Tokelau <option value="Tonga">Tonga <option value="Trinidad and Tobago">Trinidad and Tobago <option value="Tunisia">Tunisia <option value="Turkey">Turkey <option value="Turkmenistan">Turkmenistan <option value="Turks and Caicos Islands">Turks &amp; Caicos Isl. <option value="Tuvalu">Tuvalu <option value="U.S. Minor Outlying Islands">U.S.Minor Outlying Isl. <option value="Uganda">Uganda <option value="Ukraine">Ukraine <option value="United Arab Emirates">United Arab Emirates <option value="United Kingdom">United Kingdom <option value="United States of America">U.S.A. <option value="Uruguay">Uruguay <option value="Uzbekistan">Uzbekistan <option value="Vanuatu">Vanuatu <option value="Vatican City">Vatican City <option value="Venezuela">Venezuela <option value="Vietnam">Vietnam <option value="Virgin Islands">Virgin Islands <option value="Wallis and Futuna Islands">Wallis &amp; Futuna Isl. <option value="Western Sahara">Western Sahara <option value="Yemen">Yemen <option value="Yugoslavia (Former)">Yugoslavia (Former) <option value="Zaire">Zaire <option value="Zambia">Zambia <option value="Zimbabwe">Zimbabwe';






function request_form(client)
{
document.write('<br><div align="center"><form name="reqform" action="http://'+siteURL+'/php-bin/submit_req_form.php" method="post" onsubmit="return validate_req_form(this)"><input type="hidden" name="client_name" value="'+client+'"> <input type="hidden" name="referer" value="'+window.location+'"><input type="hidden" name="sitename" value="'+sitename+'"><input type="hidden" name="siteURL" value="'+siteURL+'">');

document.write('<table cellpadding="1" border="0" cellspacing="0" align="center"><tr><td align="center" colspan="2"><strong>Request Information Form</strong></td></tr><tr><td>*Desired Course: </td><td style="padding-left:4px "><select name="department" style="width: 180px;" class="font11"> <option value="Animation">Animation</option><option value="Fine Arts">Fine Arts</option><option value="Fashion Technology/Design">Fashion Technology/Design</option></select></td></tr><tr><td>*Current Qualification: </td><td style="padding-left:4px "><input name="qualification" type="text" maxlength="50"></td></tr><tr><td>*First Name:</td><td style="padding-left:4px "><input name="fname" type="text" maxlength="50"></td></tr><tr><td>*Last Name: </td><td style="padding-left:4px "><input name="lname" type="text" maxlength="50"></td></tr><tr><td>*E-mail Address: </td><td style="padding-left:4px "><input name="email_id" type="text" maxlength="50"></td></tr><tr><td>*Address: </td><td style="padding-left:4px "><input name="address" type="text" maxlength="100"></td></tr><tr><td>*City: </td><td style="padding-left:4px "><input name="city" type="text" maxlength="25"></td></tr><tr><td>*State: </td><td style="padding-left:4px "><input name="state" type="text" maxlength="25"></td></tr><tr><td>*Country: </td><td style="padding-left:4px "><select size="1" name="Country" class="fldsn"> <option value="NA" selected>Select Country '+cntdis+'</option></select></td></tr><tr><td>*Primary Phone Number: </td><td style="padding-left:4px "><input name="phone" type="text" maxlength="25"></td></tr><tr><td>Mobile Number: </td><td style="padding-left:4px "><input name="mobile_no" type="text" maxlength="15"></td></tr><tr height="10"><td colspan="2"></td></tr><tr><td colspan="2" align="center"><input name="submit" type="submit" value="Submit">&nbsp;&nbsp; &nbsp;&nbsp;<input name="reset" type="reset" value="Reset"></td></tr></table></form>');
}