document.write('<!-- phpForms.net form BEGIN -->');
document.write('<style>');
document.write('<!--');
document.write('.phpForms_pgtitle');
document.write('{');
document.write('    font-family : Arial;');
document.write('    font-size   : 18px;');
document.write('    color       : #1200d9;');
document.write('    font-weight : bold;');
document.write('}');
document.write('.phpForms_btn');
document.write('{');
document.write('    border-top-width    : 1px;');
document.write('    border-left-width   : 1px;');
document.write('    border-bottom-width : 1px;');
document.write('    border-right-width  : 1px;');
document.write('    border-top-color    : #e4e4e4;');
document.write('    border-left-color   : #e4e4e4;');
document.write('    border-right-color  : #c1c1c1;');
document.write('    border-bottom-color : #c1c1c1;');
document.write('    font-family         : Verdana, Arial, Helvetica, sans-serif;');
document.write('    color               : #000000;');
document.write('}');
document.write('-->');
document.write('</style>');


FPList_frm_1058d4089b = new Array();

   var aIds_frm_1058d4089b = Array( 'pg_6bb904134f' );
   var aId_frm_1058d4089b  = Array ();
function ChangePage_frm_1058d4089b( to_hide, to_show )
{
   var tbl_hide = document.getElementById( aIds_frm_1058d4089b[to_hide] );
   var tbl_show = document.getElementById( aIds_frm_1058d4089b[to_show] );

   if ( typeof(tbl_hide)=='object' && tbl_hide!=null )
    if ( typeof(tbl_show)=='object' && tbl_show!=null )
    {
       tbl_hide.style.display = 'none';
       tbl_show.style.display = '';
    }
	
}
function NotEmpty( old_res, id, field_title )
{
   if ( old_res==0 )
   {
      var el = document.getElementById( id );
      if ( typeof(el)=='object' && el!=null )
        if ( el.value=='' )
        {
           alert( 'You should fill "' + field_title + '"' );
           return 1;
        }
   }
   return 0;
}
function Email( old_res, id, field_title )
{ 
   if ( old_res==0 )
   {
      var el = document.getElementById( id );
      if ( typeof(el)=='object' && el!=null && el.value!='' )
      {
         var re = /^[a-zA-Z0-9_\.\-]+@([a-zA-Z0-9][a-zA-Z0-9-]+\.){1,3}[a-zA-Z]{2,6}$/;

         if (el.value.search(re) != -1 )  return 0;
         else
         {
            alert( '"'+field_title+'" must be email' );
            return 1;
         }
      }
   }
   return 0;
}






document.write('<form name=\"frm_1058d4089b\" id=\"frm_1058d4089b\" method=\"POST\" enctype=\"multipart/form-data\" action=\"http://mchis.wforms.net/index.php?sid=0\" onSubmit=\"return false;\">');
document.write('<input type=\"hidden\" name=\"act\" value=\"idx\">');
document.write('<input type=\"hidden\" name=\"code\" value=\"01\">');
document.write('<input type=\"hidden\" name=\"fid\" value=\"1058d4089b\">');



function CheckPage_frm_1058d4089b_6bb904134f()
{
   var nResult = 0;
      nResult += NotEmpty( nResult, 'fld_d2603a058a','Nombre Completo:' );
   nResult += Email( nResult, 'fld_22f7c1e2bd','E-mail:' );

   if ( nResult == 0 )
   {  
      document.getElementById('loading_frm_1058d4089b').style.display='inline';

                                              document.getElementById('imgcode_code_frm_1058d4089b').style.display='none';

											  if (arguments[0] == 1)
											  {
												window.temp_1058d4089b = 'yes';
											  } else
												{
													window.temp_1058d4089b = 'no';
												}
											  CheckImg_frm_1058d4089b();
											  return;
                                               

      if (1)
      {
         var el = document.getElementById( 'frm_1058d4089b' );
         if ( typeof(el)=='object' && el != null )
		 {
			el.submit()
		}
      }
      else 
        {
            ChangePage_frm_1058d4089b( 0, 1 );
            document.location.href="#";
        }
   } 
}
function SetFDate(fld_id)
{
	var cur_date = new Date();
	var minutes = cur_date.getMinutes();
	var hour= cur_date.getHours();
	var day = cur_date.getDate();
	var month = cur_date.getMonth();
	var year = cur_date.getFullYear();
	var eDay = document.getElementById('fld_d_' + fld_id);
	if ( typeof(eDay )=='object' && eDay != null )
	{
		eDay.options[day-1].selected = 'selected';
	}
	var eHour= document.getElementById('fld_h_' + fld_id);
	if ( typeof(eHour)=='object' && eHour != null )
	{
		eHour.options[hour].selected = 'selected';
	}
	var eMinutes = document.getElementById('fld_i_' + fld_id);
	if ( typeof(eMinutes)=='object' && eMinutes != null )
	{
		eMinutes.options[minutes].selected = 'selected';
	}
	var eMonth = document.getElementById('fld_m_' + fld_id);
	if ( typeof(eMonth)=='object' && eMonth != null )
	{
		eMonth.options[month].selected = 'selected';
	}
	var eYear = document.getElementById('fld_y_' + fld_id);
	if ( typeof(eYear)=='object' && eYear != null )
	{
		for(i=0;i<eYear.length; i++)
		{
			if (eYear.options[i].value == year)
			{
				eYear.options[i].selected = 'selected';
			}
		}
	}
}



document.write('     <!-- Page -->');
document.write('     <table id=\"pg_6bb904134f\" border=\"0\" cellpadding=\"2\" cellspacing=\"1\" width=\"500\" bgcolor=\"#F0F8FF\" class=\"phpForms_main\" style=\"display:table;border: solid 1px #777777;\">');
document.write('      <tr>  <!-- Page title -->');
document.write('          <td colspan=\"2\" align=\"center\" vAlign=\"top\">');
document.write('             <span class=\"phpForms_pgtitle\"></span>');
document.write('          </td>');
document.write('      </tr> <!-- /Page title -->');

document.write('      <tr>  <!-- Page top text -->');
document.write('          <td colspan=\"2\" align=\"center\">');
document.write('          ');
document.write('          </td>');
document.write('      </tr> <!-- /Page top text -->');

document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Comentarios</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <textarea name=\"fld_4d5c371d11\" id=\"fld_4d5c371d11\" rows=\"5\" style=\"width:100%;\"></textarea>');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Nombre Completo:</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_d2603a058a\"   id=\"fld_d2603a058a\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Telefono:</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_981708dcc1\"   id=\"fld_981708dcc1\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">E-mail:</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_22f7c1e2bd\"   id=\"fld_22f7c1e2bd\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');

document.write('<tr>');
document.write('    <td>');
document.write('     <img src=\"http://mchis.wforms.net/index.php?frm=1058d4089b&randm=\"+ randim_frm_1058d4089b + \"\" name=\"captcha_frm_1058d4089b\"><br>');
document.write('     <input type=\"hidden\" name=\"imgcode_id_frm_1058d4089b\" value=\'\'>');
document.write('     <a href=\"javascript:changeAccessCodeImg_frm_1058d4089b();\">Reload image</a>');
document.write('    </td>');
document.write('    <td>');
document.write('	 <img src=\"http://mchis.wforms.net/img-code/loading.gif\" id=\"loading_frm_1058d4089b\" name=\"loading\" style=\"display: none\"><br>');
document.write('	 <b>Enter the code you see on the image:</b><br />');
document.write('     <input type=\"text\" name=\"imgcode_code\" id=\"imgcode_code_frm_1058d4089b\" value=\'\' style=\"width:220px;\">');
document.write('    </td>	 ');
document.write('</tr>');
document.write('&nbsp;');


function changeAccessCodeImg_frm_1058d4089b()
{
   var randim_frm_1058d4089b = Math.random();
   document.images.captcha_frm_1058d4089b.src = "http://mchis.wforms.net/index.php?frm=1058d4089b&randm="+ randim_frm_1058d4089b + "";
   document.forms['frm_1058d4089b'].imgcode_id_frm_1058d4089b.value =+ randim_frm_1058d4089b + "";
 }
 changeAccessCodeImg_frm_1058d4089b();

 function CheckImg_frm_1058d4089b()
{  
   var s = document.createElement('script');
   s.setAttribute('type','text/javascript');
   var cl_code = document.getElementById('imgcode_code_frm_1058d4089b');
   checimg_frm_1058d4089b = cl_code.value;
   randim_frm_1058d4089b = document.forms['frm_1058d4089b'].imgcode_id_frm_1058d4089b.value;
   document.documentElement.firstChild.appendChild(s);

    ff_onload_called_frm_1058d4089b=false;
	s.setAttribute('src', "http://mchis.wforms.net/index.php?frm=1058d4089b&chrandm=" + randim_frm_1058d4089b + "&checimg=" + checimg_frm_1058d4089b + "");
	s.setAttribute('onload', "ff1_frm_1058d4089b()"); 

}

var ff_onload_called_frm_1058d4089b=false;

function ff1_frm_1058d4089b()
{  
    if(ff_onload_called_frm_1058d4089b)
        return;
    ff_onload_called_frm_1058d4089b=true;
    
   document.getElementById('loading_frm_1058d4089b').style.display='none';
   document.getElementById('imgcode_code_frm_1058d4089b').style.display='';
   
   if (ci == 3)
    {
      alert("Sorry, the code you've entered is invalid. Please try again.");
      return 1;
    }
	
    if (ci == 2 )
    {
         var el = document.getElementById('frm_1058d4089b');
         if ( typeof(el)=='object' && el != null )
         {
            el.submit()
         }
    }
	
}



document.write('&nbsp;');
document.write('<tr>');
document.write('          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">');
document.write('            ');
document.write('          </td>');
document.write('      </tr>');
document.write('<tr>');
document.write('          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <!-- Buttons -->');
document.write('          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">');
document.write('<input type=\"button\" id=\"subbut_1058d4089b\" value=\"Enviar\" onClick=\'CheckPage_frm_1058d4089b_6bb904134f(0);\' style=\"width:30%; background-color : #a2a2a2\" class=\"phpForms_btn\">');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>  <!-- Page bottom text -->');
document.write('          <td colspan=\"2\" align=\"center\">');
document.write('          <hr>');
document.write('              ');
document.write('          </td>');
document.write('      </tr> <!-- /Page bottom text -->');

document.write('     </table>');
document.write('     <!-- /Page -->');


document.write('</form>');


document.write('<!-- /phpForms.net form END -->');