<form name="form1" method="post" action="http://www.brethetbarnum.com/cgi-sys/formmail.pl"> <input type="hidden" name="recipient" value="anne@brethetbarnum.com"> <p class="hdr"><strong> <input name="subject" type="hidden" id="subject" value="Feedback Form"> <input name="redirect" type="hidden" value="thanks.htm"> Contact Information</strong></p> <table width="100%" border="0"> <tr> <td><p>Brethet, Barnum & Associates Inc<br> 703 Evans Ave., Suite 300<br> Toronto, Ontario<br> M9C 5E9 </p> <p>Phone 416-621-4900<br> Toll-free 888-284-8465<br> </p></td> <td><a href="javascript:;" onClick="MM_openBrWindow('iframe/maplarge.htm','','width=403,height=319')"><img src="images/mapthumb.gif" alt="Click map to see larger version" width="188" height="149" border="0"></a></td> </tr> <tr> <td colspan="2">click on map to enlarge area or <a href="http://www.mapblast.com/(q5oogb3du0a4xr45mrwkl155)/DirectionsFind.aspx" target="_blank">click here for driving directions</a></td> </tr> </table> <br> <table border="0"> <tr> <td width="91">Anne Brethet</td> <td width="173"><a href="mailto:anne@brethetbarnum.com">anne@brethetbarnum.com</a></td> </tr> <tr> <td>Phyllis Chrzan</td> <td><a href="mailto:phyllis@brethetbarnum.com">phyllis@brethetbarnum.com</a></td> </tr> <tr> <td>Bob Shiley</td> <td><a href="mailto:bob@brethetbarnum.com">bob@brethetbarnum.com</a></td> </tr> </table> <p>Questions or submissions to <a href="mailto:info@brethetbarnum.com">info@brethetbarnum.com</a></p> <p class="hdr"><strong> Contact Us Form </strong></p> <table width="100%" border="0"> <tr> <td width="24%">Name</td> <td width="76%"><input name="Name" type="text" id="Name"> </td> </tr> <tr> <td valign="top">Address</td> <td><textarea name="textarea" cols="30" rows="4"></textarea> </td> </tr> <tr> <td><strong>Phone Number</strong></td> <td> </td> </tr> <tr> <td>Home</td> <td><input name="home#" type="text" id="home#"> </td> </tr> <tr> <td>Work</td> <td><input name="Work#" type="text" id="Work#"> </td> </tr> <tr> <td>Cell</td> <td><input name="Cell#" type="text" id="Cell#"> </td> </tr> <tr> <td>Alternate Contact Number </td> <td><input name="Alternate#" type="text" id="Alternate#"> <br> (permanent number such as a parent, if we lose touch) </td> </tr> <tr> <td>Education</td> <td><input name="Education" type="text" id="Education"> </td> </tr> <tr> <td>Present Position</td> <td><input name="Present Position" type="text" id="Present Position"> </td> </tr> <tr> <td>Years in Industry</td> <td><input name="Years in Industry" type="text" id="Years in Industry"> </td> </tr> <tr> <td>Desired Position </td> <td><input name="Desired Position" type="text" id="Desired Position"> </td> </tr> </table> <p class="hdr"><strong>Feedback Form</strong></p> <p><strong>Please let us know how we are doing.</strong></p> <table width="100%" border="0"> <tr> <td width="23%" valign="top">Knowledge of industry</td> <td width="77%"><textarea name="Knowledge" cols="30" rows="5" id="Knowledge"></textarea> </td> </tr> <tr> <td valign="top">Professionalism</td> <td><textarea name="Professionalism" cols="30" rows="5" id="Professionalism"></textarea> </td> </tr> <tr> <td valign="top">Helpfulness </td> <td><textarea name="Helpfulness" cols="30" rows="5" id="Helpfulness"></textarea> </td> </tr> <tr> <td valign="top">Follow-up </td> <td><textarea name="Followup" cols="30" rows="5" id="Followup"></textarea> </td> </tr> <tr> <td valign="top">Other Comments </td> <td><textarea name="Comments" cols="30" rows="5" id="Comments"></textarea></td> </tr> <tr> <td colspan="2" valign="top"> </td> </tr> <tr> <td colspan="2" valign="top"><input type="submit" name="Submit" value="Submit"> <input type="reset" name="Reset" value="Reset"></td> </tr> </table> </form>
