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	<div class="form-group row">
	    <label class="col-sm-4 control-label">First Name<b class="madatorystar">*</b></label>
	    <div class="col-sm-8">
	      <input type="text" value="" name="DATA[FNAME]" size="45" maxlength="255" dir="ltr" id="CONTACT_FNAME" class=" mandatory form-control" >
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	    <div class="col-sm-8">
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	<div class="form-group row">
	    <label class="col-sm-4 control-label">E-mail<b class="madatorystar">*</b></label>
	    <div class="col-sm-8">
	      <input type="text" value="" name="DATA[EMAIL]" size="45" maxlength="255" dir="ltr" id="CONTACT_EMAIL" class=" mandatory form-control" >
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	<div class="form-group row">
	    <label class="col-sm-4 control-label">Phone</label>
	    <div class="col-sm-8">
	     <input type="text" value="" name="DATA[PHONE]" size="45" maxlength="255" dir="ltr" id="CONTACT_PHONE" class=" form-control" >
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	<div class="form-group row">
	    <label class="col-sm-4 control-label">Ship to Country<b class="madatorystar">*</b></label>
	    <div class="col-sm-8">
	   	<select size="1" id="CONTACT_COUNTRY" name="DATA[COUNTRY]" dir="ltr" class=" mandatory form-control form-select" ><option value="USA" class=" " >UNITED STATES</option><option value="CA" class=" " >CANADA</option><option value="MX" class=" " >MEXICO</option></select>
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  	<div class="form-group row">
	    <label class="col-sm-4 control-label">System you are interested in</label>
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	<div class="form-group row">
	    <label class="col-sm-4 control-label">Comments</label>
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<input type="hidden" name="BUFFER" value="CONTACT_US">
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<input type="hidden" name="TAG" value="CONTACT3">
<input type="hidden" name="ac" value="insert">
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<input type="hidden" name="next_section" value="contact_us_thanks">
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<input type="hidden" name="DATA[THE_TIME]" value="NOW()">


  <input type="hidden" name="onerror_tag" value="coltene">
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</FORM>

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</div>


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