<form action="http://highrisewidgets.com/process.php" method="post" onsubmit="for (var i=0; i<this.elements.length;i++) { if (this.elements[i].value == '') { alert('Please fill in all the fields.'); return false; } } this.target='hrwwin'; window.open('', 'hrwwin', 'width=400,height=300,toolbar=0');">

<input type="hidden" name="id" value="7f0e5954df424">

<table border="0">

     <tr>

          <th valign="top" align="right">First Name</th>

          <td><input name="first-name" type="text"></td>

     </tr>

     <tr>

          <th valign="top" align="right">Last Name</th>

          <td><input name="last-name" type="text"></td>

     </tr>

     <tr>

          <th valign="top" align="right">Email Address</th>

          <td><input name="email-address" type="text"></td>

     </tr>

     <tr>

          <th valign="top" align="right">Phone Number</th>

          <td><input name="phone-number" type="text"></td>

     </tr>

     <tr>

          <th valign="top" align="right">State</th>

          <td><input name="state" type="text"></td>

     </tr>

     <tr>

          <th valign="top" align="right">Zip</th>

          <td><input name="zip" type="text"></td>

     </tr>

     <tr>

          <th valign="top" align="right">Note</th>

          <td><textarea rows="10" cols="30" name="note"></textarea></td>

     </tr>

     <tr><td></td><td><input type="submit" value="Submit"></td></tr>

</table>

</form>