Electrical Supplies, Lighting Fixtures, Switchgear, Electric Heat, Washington DC/title>   <script language="JavaScript">  </script>  <link rel="stylesheet" type="text/css" href="templates/css/descowashington.css"> <style type="text/css" >  </style></head> <body class="twoColFixLtHdr"> <div id="container"> <div id="header"> <div id="logo"> <a href=""><img src="/templates/images/header.jpg" width="811" height="85" alt="Dominion Electric Supply" border="none" /></a> </div> <div id="topMenu">  </div> <div id="Options"> <center> <table height="180" cellpadding="0" cellspacing="0"> <tr> <td width="161"><a href="electrical.php"><img src="/templates/images/electrical.jpg" alt="electrical" /></a></td> <td width="161"><a href="prod-resi.php"><img src="/templates/images/ligthing.jpg" alt="ligthining" /></a></td> <td width="161"><a href="prod-heat.php"><img src="/templates/images/heating.jpg" alt="heating" /></a></td> <td width="161"><a href="datacom.php"><img src="/templates/images/datacom.jpg" alt="datacom" /></a></td> <td width="161"><a href="contactus.php"><img src="/templates/images/contactus.jpg" alt="contac us" /></a></td> </tr> </table> </center> </div>  </div> <div id="sidebar1"> <ul> <li><a href="aboutus.php">About us</a></li> <li><a href="locations.php">Our Location</a></li> <li><a href="http://www.electricsmarts.com/container.aspx?tab=home&distid=11642&tid=:" target="_blank">Product Resources & Webcast</a></li> <li><a href="faqs.php">FAQs</a></li> <li><a href="literaturerequest.php">Join our mailing list</a></li> <li><a href="credit application.php">Credit Application</a></li> </ul> </div> <div id="mainContent"> <p>If you would like literature on a particular product, please complete the form below and submit it to Dominion. We will respond promptly.</p> <p><b>Literature order form</b></p> <p><font color='red'>Please type your email, email address and phone</font></p> <form method="POST" action="" name="literature"> <table width="380" border="0" cellspacing="0" cellpadding="0"> <tr> <td><b>Product Group: </b></td> <td width="230"> <select name="productgroup"> <option>Commercial Products</option> <option>Residential Lighting</option> <option>Electric Heat</option> <option>DataWorks</option> </select> </td> </tr> <tr> <td><b>Item #:</b> </td> <td width="230"> <input type="text" name="itemnumber" maxlength="30"> </td> </tr> <tr> <td><b>Manufacturer:</b> </td> <td width="230"> <input type="text" name="mfg" maxlength="30"> </td> </tr> <tr> <td><b>Number of literature pieces needed:</b></td> <td width="230"> <input type="text" name="qtyoflitpieces" maxlength="30" value="1"> </td> </tr> <tr> <td colspan="2"><b>Product description:</b> <br> <textarea name="description" cols="30"></textarea> </td> </tr> <tr> <td><b>Date required:</b> </td> <td width="230"> <input type="text" name="daterequired" maxlength="30"> </td> </tr> <tr> <td height="26"><b>Name:<font color="#FF0033"> </b></td> <td width="230" height="26"> <input type="text" name="contactname" maxlength="30" > <font color="#FF0033">(required)</font></td> </tr> <tr> <td><b>Title:</b></td> <td width="230"> <input type="text" name="title" maxlength="15"> </td> </tr> <tr> <td><b>Company: </b></td> <td width="230"> <input type="text" name="company" maxlength="50"> </td> </tr> <tr> <td height="18" colspan="2"><b>Address: </b> <br> <textarea name="address" rows="3" cols="30"></textarea> </td> </tr> <tr> <td><b>City: </b></td> <td width="230"> <input type="text" name="city" maxlength="30"> </td> </tr> <tr> <td><b>State: </b></td> <td width="230"> <input type="text" name="state" maxlength="30"> </td> </tr> <tr> <td><b>Zip:</b></td> <td width="230"> <input type="text" name="zip" maxlength="10"> </td> </tr> <tr> <td><b>Email:</b></td> <td width="230"> <input type="text" name="email" maxlength="30"> <font color="#FF0033">(required)</font></td> </tr> <tr> <td><b>Telephone:</b></td> <td width="230"> <input type="text" name="telephone" maxlength="30" > <font color="#FF0033">(required)</font></td> </tr> <tr> <td><b>Fax:</b></td> <td width="230"><b> <input type="text" name="fax" maxlength="30"> </b></td> </tr> </table> <p> <input type="checkbox" name="newsletter" value="1" checked="checked"/> Join our mailing list </p> <p>Please specifying how you would like to receive our promotional information:</p> <input type="radio" name="sendby" value="email" checked="checked"/> Email <br /> <input type="radio" name="sendby" value="mail"/> Regular mail <br /> <input type="radio" name="sendby" value="fax"/> Fax<br /> <p> <input type="submit" name="Submit" value="Submit"> <input type="reset" name="reset" value="Reset"> </p> </form> <p> </p> </div> <br class="clearfloat" /> <div align="center"> <A HREF="javascript:history.go(-1)">Back</A></div> <div id="footer"> <p>22 K Street, N.E. <br />Washington, DC 20002 <br /> 202-789-0500 Fax No. 202-289-3919 </p><br /> </div> </div> </body> </html>