<input type=hidden name='captcha_settings' value='{"keyname":"

COMP_Support_Form","fallback":"true","orgId":"00D300000000Swd","ts":""}'>
<input type=hidden name="orgid" value="00D300000000Swd">
<input type=hidden name="retURL" value="http://support.companioncorp.com/display/ALEX/Support+Form+Confirmation">

<!--  ----------------------------------------------------------------------  -->
<!--  NOTE: These fields are optional debugging elements. Please uncomment    -->
<!--  these lines if you wish to test in debug mode.                          -->
<!--  <input type="hidden" name="debug" value=1>                              -->
<!--  <input type="hidden" name="debugEmail"                                  -->
<!--  value="

csasithorn@companioncorp.com">

                                   -->
<!--  ----------------------------------------------------------------------  -->

<label for="name"

><b>Name *</b></label> <br /><input  id="name" maxlength="80" name="name" size="30" type="text" required/><br /><br />

<b>Library Name or Organization *</b> <br /><input  id="00N2J00000ApjTM" maxlength="255" name="00N2J00000ApjTM" size="

30" type="text" required/><br /><br /

>

<label for="email"

><b>Email</b></label> <br /><input  id="email" maxlength="80" name="email" size="

30" type="text" /><br /><br /

>

<label for="phone"

><b>Phone</b></label> <br /><input  id="phone" maxlength="40" name="phone" size="

30" type="text" /><br /

><br />

<label for="subject"

><b>Subject *</b></label> <br /><input  id="subject" maxlength="80" name="subject" size="

30" type="text" required/><br /><br /

>

<label for="description"

><b>Description</b></label> <br /><textarea name="description" rows="10" cols="70"><

/textarea><br /><br />
<b>*</b> indicates a required field
<p></p>

<input type="hidden"  id="external" name="external" value="1" /><br>

<div class="g-recaptcha" data-sitekey="

6LdR0cMUAAAAAIQLgnX2JqmgtmTq92uTc1rLYAqU"></div><br>
<input type="submit" name="submit">

</form>