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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
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<meta name="description" content="">
<meta name="keywords" content="contact, message, location, apply,">
<link href="default.css" rel="stylesheet" type="text/css" />

   <title>Contact Us - Provena United Samaritans Medical Center</title>

<style type="text/css">
	@import url(default.css);
</style>


            <script language="JavaScript" type="text/javascript">
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							runMouseOvers = true;
							return true;
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						function BillzMouseOutTimer() {
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							TimerID = setTimeout("nbLayerRestore()",5000);
							return true;
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						function RestoreAll() {
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							nbLayerRestore();
							return true;
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						function BillzMouseoverRestore() {
							return nbMouseoverRestore();
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                  {
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                     {
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                        {
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						function BillzLayerRestore() {
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							return true;
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						function BillzArrayPop(aryArray) { //Implement Array Pop 'cause IE cant handle it before 5.5
							var varItemToPop = null;
							if (aryArray[aryArray.length - 1]) {
								varItemToPop = aryArray[aryArray.length - 1];
								aryArray[aryArray.length] = null;
							}
							return varItemToPop;
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                  //v3.0 name changed to avoid clash with possible other JS in content, this function complements of MM Dreamweaver
						function BillzNavBarMM_findObj(n, d) {
						  	var p,i,x;
						
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								return registeredObjects[n];
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						  			x = BillzNavBarMM_findObj(n, d.layers[i].document);
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							registeredObjects[n] = x;
						
						 	return x;
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						function BillzArrayContains() {
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								if (o = BillzNavBarMM_findObj(n)) {
									aryNavBarLayers[n] = o;
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							return true;
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						function BillzNavBarMM_showHideLayers() {
						//v3.0 name changed, this function complements of MM Dreamweaver with customizations by Bill Heller
							var i = 0;
							var x = "";
							var obj = null;
							var v = null;
							var p = null;
							var args = BillzNavBarMM_showHideLayers.arguments;

							if (args[args.length - 1] != "menu") {
								nbMouseOutTimer();
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						function BillzNavBarRestoreLayers() {
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						function NavBarLayer() {
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							this.isDefault = true;
							this.MOutLayer = arg[2];
							return true;
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						function BillzNavMove() {
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                  {
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                     {
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                     {
								otherl = BillzNavBarMM_findObj("BillzLayer");
								otherl.visibility = viz;
							} else {
								setTimeout("nbNavMove()", nbTime);
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							return true;
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						function NavBar_openadmin() {
							window.open('admin/', 'SiteAdmin', 'height=screen.availheight,width=screen.availwidth,scrollbars=1,toolbar=0,directories=0,status=0,menubar=0,resizable=1');
							return true;
						}
						window.onload = FullyLoaded;
					//-->
				</script>
				
		<style type="text/css">
			@import url(module.css);
		</style>
	</head>



	
	<body style="background-color:#75ACD5;">
	<div align="center">
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			<td background="images/bkg_leftgradient.jpg" width="8"></td>
			<td valign="top" align="left" style="background-color:#fff;">
				
				
					
				
				<table style="border-bottom:10pt solid #FFFFFF;">
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						<td align="left" valign="top">
							<a href="homepage.cfm?id=1&amp;oTopId=0">
							
								
									<img src="images/logos/logo_unitedsam.jpg" border="0" alt="" />
								
							
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<style name="text/css" class="search">		
td.search {background-color: transparent; background-image: URL(images/clear.gif); font-family: Helvetica; font-weight: 
700; font-size: 8pt; color: 666666; }
				
	</style>

		<table border="0" cellpadding="0" cellspacing="0" background="" align= "top" class="search">		
		<form action="body.cfm?id=109" method="POST">		
		<input type="hidden" name="action" value="list">	
		<input type="hidden" name="search_areas_id" value="">	
		<input type="hidden" name="includewhat" value="">
			
			<tr class="search">							
				
					<td class="search" style="padding-left: 10px; ">Search</td>
				
				
					<td class="search"><input type="text" name="keywords" size="15" style="color: #3300FF; " value="Search Intranet"></td>
							
				
					<td class="search"><input type="IMAGE" src="images/go_button.gif" border="0" width="32" height="24" style="border: 0px; "></td>
				
			</tr>
		</form>
			<tr class="search"><td class="search" colspan="3" align="right">
				<a href="body.cfm?id=109">Advanced Search...</a>
			</td></tr>
		</table>
	 


									</td>
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							</table>
						</td>
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				</table>
				
				<table>
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						<td align="left" valign="top">
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var sm_reEmail = /^\s*[-.:\w]+@([a-zA-Z0-9][-a-zA-Z0-9]+[a-zA-Z0-9]|[a-zA-Z0-9]{1,2})(\.([a-zA-Z0-9][-a-zA-Z0-9]+[a-zA-Z0-9]|[a-zA-Z0-9]{1,2}))+\s*$/i;
var sm_reMultiEmails = /^\s*([-.:\w]+@([a-zA-Z0-9][-a-zA-Z0-9]+[a-zA-Z0-9]|[a-zA-Z0-9]{1,2})(\.([a-zA-Z0-9][-a-zA-Z0-9]+[a-zA-Z0-9]|[a-zA-Z0-9]{1,2}))+)(\s*[,;]\s*[-.:\w]+@([a-zA-Z0-9][-a-zA-Z0-9]+[a-zA-Z0-9]|[a-zA-Z0-9]{1,2})(\.([a-zA-Z0-9][-a-zA-Z0-9]+[a-zA-Z0-9]|[a-zA-Z0-9]{1,2}))+)*\s*$/i;
var sm_reDate = /^(?=\d)(?:(?:(?:(?:(?:0?[13578]|1[02])(\/|-|\.)31)\1|(?:(?:0?[1,3-9]|1[0-2])(\/|-|\.)(?:29|30)\2))(?:(?:1[6-9]|[2-9]\d)?\d{2})|(?:0?2(\/|-|\.)29\3(?:(?:(?:1[6-9]|[2-9]\d)?(?:0[48]|[2468][048]|[13579][26])|(?:(?:16|[2468][048]|[3579][26])00))))|(?:(?:0?[1-9])|(?:1[0-2]))(\/|-|\.)(?:0?[1-9]|1\d|2[0-8])\4(?:(?:1[6-9]|[2-9]\d)?\d{2}))($|\ (?=\d)))?(((0?[1-9]|1[012])(:[0-5]\d){0,2}(\ [AP]M))|([01]\d|2[0-3])(:[0-5]\d){1,2})?$/;
var sm_reEuroDate = /^((((0?[1-9]|[12]\d|3[01])[\.\-\/](0?[13578]|1[02])[\.\-\/]((1[6-9]|[2-9]\d)?\d{2}))|((0?[1-9]|[12]\d|30)[\.\-\/](0?[13456789]|1[012])[\.\-\/]((1[6-9]|[2-9]\d)?\d{2}))|((0?[1-9]|1\d|2[0-8])[\.\-\/]0?2[\.\-\/]((1[6-9]|[2-9]\d)?\d{2}))|(29[\.\-\/]0?2[\.\-\/]((1[6-9]|[2-9]\d)?(0[48]|[2468][048]|[13579][26])|((16|[2468][048]|[3579][26])00)|00)))|(((0[1-9]|[12]\d|3[01])(0[13578]|1[02])((1[6-9]|[2-9]\d)?\d{2}))|((0[1-9]|[12]\d|30)(0[13456789]|1[012])((1[6-9]|[2-9]\d)?\d{2}))|((0[1-9]|1\d|2[0-8])02((1[6-9]|[2-9]\d)?\d{2}))|(2902((1[6-9]|[2-9]\d)?(0[48]|[2468][048]|[13579][26])|((16|[2468][048]|[3579][26])00)|00))))$/;
function sm_Trim(s) {
	var mystr = s;
	var myArr = sm_reEmpty.exec(mystr);
	if (myArr != null) {
		return "";
	}
	var myArr = sm_reLeading.exec(mystr);
	if (myArr != null) {
		if (RegExp.rightContext) {
			mystr = RegExp.rightContext;
		} else {
			mystr = mystr.substring(RegExp.$1.length, mystr.length);
		}
	}
	myArr = sm_reEnding.exec(mystr);
	if (myArr != null) {
		if (RegExp.leftContext) {
			mystr = RegExp.leftContext;
		} else {
			mystr = mystr.substring(0, (mystr.length - RegExp.$1.length));
		}
	}
	return mystr;
}
function sm_StripCRLF(s) {
	return s.replace(sm_reCRLF, " ");
}
function sm_IsArray(o) {
	return (typeof(o) == "object" && typeof(o.length) == "number");
}
function sm_IsRadio(o) {
	return (o.type == "radio");
}
function sm_IsCheckBox(o) {
	return (o.type == "checkbox");
}
function sm_IsFileUpload(o) {
	return (o.type == 'file');
}
function sm_IsSelectMulti(o) {
	return (o.type == "select-multiple");
}
function sm_IsSelectOne(o) {
	return (o.type == "select-one");
}
function sm_IsSelect(o) {
	return (sm_IsSelectMulti(o) || sm_IsSelectOne(o));
}
function sm_IsHidden(o) {
	return (o.type == "hidden");
}
function sm_IsInputText(o) {
	return (o.type == "text");
}
function sm_IsTextarea(o) {
	return (o.type == "textarea");
}
function sm_IsPassword(o) {
	return (o.type == "password");
}
function sm_IsSubmit(o) {
	return (o.type == "submit");
}
function sm_IsDate(s) {
	if (sm_reDate.test(s))
	{
		var oDate = Date.parse(s);
		if (isNaN(oDate)) {
			return false;
		}
		oDate = new Date(s);
		if (oDate.getFullYear() < 1900) {
			return false;
		}
		return true;
	}
	return false;
}
function sm_IsEuroDate(s) {
	if (sm_reEuroDate.test(s))
	{
		return true;
	}
	return false;
}
function sm_IsTime(s) {
	var dtToday = new Date();
	var strToday = (dtToday.getMonth()+1) + "/" + dtToday.getDate() + "/" + dtToday.getFullYear();

	var lgnTest = Date.parse(strToday+" "+s);
	if (isNaN(lgnTest)) return false;
	var datTest = new Date();
	datTest.setTime(lgnTest);
	if (datTest.getFullYear() < 1900) return false;
	return true;
}
function sm_IsFloat(s) {
	return (!isNaN(parseFloat(s)));
}
function sm_IsInt(s) {
	return (sm_reInteger.test(s));
}
function sm_IsWithinRange(n, lower, upper) {
	var f = parseFloat(n);
	if (isNaN(f)) return true;
	var isOK = true;
	var l = parseFloat(lower);
	if (!isNaN(l) && (l > f)) {
		isOK = false;
	}
	var u = parseFloat(upper);
	if (!isNaN(u) && (f > u)) {
		isOK = false;
	}
	return isOK;
}
function sm_IsEmail(s) {
	return (sm_reEmail.test(s));
}
function sm_IsMultiEmails(s) {
	return (sm_reMultiEmails.test(s));
}
function sm_IsACheckObj(o, re) {
	if (!o.name) return false;
	return re.test(o.name);
}
function sm_IsRequired(o) {
	return sm_IsACheckObj(o, sm_reIsRequired);
}
function sm_IsIntegerObj(o) {
	return sm_IsACheckObj(o, sm_reIsInteger);
}
function sm_IsFloatObj(o) {
	return sm_IsACheckObj(o, sm_reIsFloat);
}
function sm_IsDateObj(o) {
	return sm_IsACheckObj(o, sm_reIsDate);
}
function sm_IsEuroDateObj(o) {
	return sm_IsACheckObj(o, sm_reIsEuroDate);
}
function sm_IsTimeObj(o) {
	return sm_IsACheckObj(o, sm_reIsTime);
}
function sm_IsRangeObj(o) {
	return sm_IsACheckObj(o, sm_reIsRange);
}
function sm_IsEmailObj(o) {
	return sm_IsACheckObj(o, sm_reIsEmail);
}
function sm_IsMultiEmailsObj(o) {
	return sm_IsACheckObj(o, sm_reIsMultiEmails);
}
function sm_GetAnObjToCheck(o, re) {
	if (!sm_IsACheckObj(o, re)) return null;
	var arrName = re.exec(o.name);
	if (arrName == null) return null;
	return (o.form[arrName[1]]);
}
function sm_GetRequiredObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsRequired);
}
function sm_GetIntegerObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsInteger);
}
function sm_GetFloatObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsFloat);
}
function sm_GetDateObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsDate);
}
function sm_GetEuroDateObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsEuroDate);
}
function sm_GetTimeObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsTime);
}
function sm_GetRangeObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsRange);
}
function sm_GetEmailObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsEmail);
}
function sm_GetMultiEmailsObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsMultiEmails);
}
function sm_CheckRequiredElement(o) {
	if (typeof(o) != "object") return false;
	if (sm_IsSelectOne(o)) {
		if (o.selectedIndex < 0) return false;
		var objoption = o.options[o.selectedIndex];
		return (objoption.value.length > 0);
	} else if (sm_IsSelectMulti(o)) {
		if (o.selectedIndex < 0) return false;
		var x;
		var isOK = false;
		for (x = 0; x < o.length && !isOK; x++) {
			isOK = o.options[x].selected && o.options[x].value.length > 0;
		}
		return isOK;
	} else if (sm_IsRadio(o) || sm_IsCheckBox(o)) {
		return o.checked;
	} else if (sm_IsHidden(o) || sm_IsInputText(o) || sm_IsTextarea(o) || sm_IsPassword(o)) {
		var strValue = sm_Trim(o.value);
		return (strValue.length > 0);
	} else if (sm_IsSubmit(o)) {
		return true;
	} else if (sm_IsArray(o)) {
		var x;
		var isOK = false;
		for (x = 0; x < o.length && !isOK; x++) {
			isOK = sm_CheckRequiredElement(o[x]);
		}
		return isOK;
	} else if (sm_IsFileUpload(o)) {
		// we don't know for sure due to client-side security.
		// depend on server side checks.
		return true;
	} else {
		return false;
	}
}
function sm_IsThisRequired(ho, re) {
	var arrName = re.exec(ho.name);
	if (arrName == null) return null;
	var strName = arrName[1];
	if (ho.form[strName+"_required"]) {
		return true;
	} else {
		return false;
	}
}
function sm_CheckValueTypeElement(o, fn, breq) {
	if (typeof(o) != "object") return true;
	if (sm_IsSelectOne(o)) {
		if (o.selectedIndex < 0) return true;
		var objoption = o.options[o.selectedIndex];
		if (fn(objoption.value)) {
			return true;
		} else if (breq) {
			return false;
		} else {
			// Not required but it is not of this type.
			return (objoption.value.length == 0);
		}
	} else if (sm_IsSelectMulti(o)) {
		if (o.selectedIndex < 0) return true;
		var x;
		var isOK = true;
		for (x = 0; x < o.length && isOK; x++) {
			if (o.options[x].selected) {
				isOK = fn(o.options[x].value);
				if (!(isOK || breq)) {
					isOK = (o.options[x].value.length == 0);
				}
			}
		}
		return isOK;
	} else if (sm_IsRadio(o) || sm_IsCheckBox(o)) {
		if (o.checked) {
			if (fn(o.value)) {
				return true;
			} else if (breq) {
				return false;
			} else {
				// Not required but it is not of this type.
				return (o.value.length == 0);
			}
		} else {
			return true;
		}
	} else if (sm_IsHidden(o) || sm_IsInputText(o) || sm_IsTextarea(o) || sm_IsPassword(o)) {
		if (fn(o.value)) {
			return true;
		} else if (breq) {
			return false;
		} else {
			// Not required but it is not of this type.
			return (o.value.length == 0);
		}
	} else if (sm_IsArray(o)) {
		var x;
		var isOK = true;
		for (x = 0; x < o.length && isOK; x++) {
			// Possible Recursion
			isOK = sm_CheckValueTypeElement(o[x], fn, breq);
		}
		return isOK;
	} else {
		return true;
	}
}
function sm_CheckIntegerElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsInteger);
	return sm_CheckValueTypeElement(o, sm_IsInt, breq);
}
function sm_CheckFloatElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsFloat);
	return sm_CheckValueTypeElement(o, sm_IsFloat, breq);
}
function sm_CheckDateElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsDate);
	return sm_CheckValueTypeElement(o, sm_IsDate, breq);
}
function sm_CheckEuroDateElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsEuroDate);
	return sm_CheckValueTypeElement(o, sm_IsEuroDate, breq);
}
function sm_CheckTimeElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsTime);
	return sm_CheckValueTypeElement(o, sm_IsTime, breq);
}
function sm_CheckRangeElement(ho, fn) {
	var r = ho.value;
	var o = fn(ho);
	var breq = sm_IsThisRequired(ho, sm_reIsRange);
	var lower = "null";
	var upper = "null";
	var arrRange;
	arrRange = sm_reMinRange.exec(r);
	if (arrRange != null) {
		lower = parseFloat(arrRange[1]);
	}
	arrRange = sm_reMaxRange.exec(r);
	if (arrRange != null) {
		upper = parseFloat(arrRange[1]);
	}

	var fnBody = "return sm_IsWithinRange(n,"+lower+","+upper+");";

	var rfn = new Function("n", fnBody);
	return sm_CheckValueTypeElement(o, rfn, breq);
}
function sm_CheckEmailElement(ho, fn) {
	var o = fn(ho);
	var breq = sm_IsThisRequired(ho, sm_reIsEmail);
	return sm_CheckValueTypeElement(o, sm_IsEmail, breq);
}
function sm_CheckMultiEmailsElement(ho, fn) {
	var o = fn(ho);
	var breq = sm_IsThisRequired(ho, sm_reIsMultiEmails);
	return sm_CheckValueTypeElement(o, sm_IsMultiEmails, breq);
}
// Takes care of checkboxes, radio buttons, and hidden forms
function sm_IsDeleteActionForm(f) {
	var i = 0;
	var o = null;
	for (i = 0; i < f.elements.length; i++) {
		o = f.elements[i];
		if (o.name.toLowerCase() == "action" && (o.value.toLowerCase() == "postdelete")) {
			if (sm_IsRadio(o) || sm_IsCheckBox(o)) {
				return o.checked;
			} else if (sm_IsHidden(o)) {
				return true;
			}
		}
	}
	return false;
}
var sm_DisabledHiddenFieldNameSuffix = "_smdisabled";
function sm_removeALLrequiredhiddenfields(f) {
	var i = 0;
	var o = null;
	for (i = 0; i < f.elements.length; i++) {
		o = f.elements[i];
		if (	sm_IsHidden(o)
			&&	(	sm_IsRequired(o)
				||	sm_IsIntegerObj(o)
				||	sm_IsFloatObj(o)
				||	sm_IsDateObj(o)
				||	sm_IsEuroDateObj(o)
				||	sm_IsTimeObj(o)
				||	sm_IsRangeObj(o)
				||	sm_IsEmailObj(o)
				||	sm_IsMultiEmailsObj(o)
				)
		)
		{
			o.name += sm_DisabledHiddenFieldNameSuffix;
		}
	}
	return true;
}
var sm_DeleteConfirmationPromptText = "Are you sure you want to delete this record?\nClick 'OK' to delete, or click 'Cancel' otherwise.";
function sm_ValidateForm(f, confirmDelete) {
	var obj = f.elements;
	var x, o;
	var errmsg = "";
	var confDel = (confirmDelete == undefined || confirmDelete == null) ? false : confirmDelete;
	var bDeleteConfirmed = false;
	
	if (confDel && sm_IsDeleteActionForm(f)) {
		bDeleteConfirmed = window.confirm(sm_DeleteConfirmationPromptText);
		if (bDeleteConfirmed) {
			sm_removeALLrequiredhiddenfields(f);
		}
		return bDeleteConfirmed;
	}
	
	for (x = 0; x < obj.length; x++) {
		o = obj[x];
		if (sm_IsHidden(o)) {
			if (sm_IsRequired(o)) {
				var oreq = sm_GetRequiredObj(o);
				if (!sm_CheckRequiredElement(oreq)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsIntegerObj(o)) {
				if (!sm_CheckIntegerElement(o, sm_GetIntegerObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsFloatObj(o)) {
				if (!sm_CheckFloatElement(o, sm_GetFloatObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsDateObj(o)) {
				if (!sm_CheckDateElement(o, sm_GetDateObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsEuroDateObj(o)) {
				if (!sm_CheckEuroDateElement(o, sm_GetEuroDateObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsTimeObj(o)) {
				if (document.getElementById(o.name.replace(/_time$/,""))){
					document.getElementById(o.name.replace(/_time$/,"")).value = document.getElementById(o.name.replace(/_time$/,"")).value.replace(/\./g,"");
				}
				if (!sm_CheckTimeElement(o, sm_GetTimeObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsRangeObj(o)) {
				if (!sm_CheckRangeElement(o, sm_GetRangeObj)) {
					errmsg += "* " + o.name + " is restricted to " + sm_StripCRLF(o.value) + "\n";
				}
			} else if (sm_IsEmailObj(o)) {
				if (!sm_CheckEmailElement(o, sm_GetEmailObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsMultiEmailsObj(o)) {
				if (!sm_CheckMultiEmailsElement(o, sm_GetMultiEmailsObj)) {
					errmsg += "* " + o.value + "\n";
				}
			}
		}
	}
	if (errmsg.length > 0) {
		window.alert(errmsg);
		return false;
	}
	return true;
}
//-->
</script><script type="text/javascript">
			function updateslave(master) {}
			</script>
		<form class="metanew" action="http://www.provena.org/usmc/body.cfm?xyzpdqabc=0&amp;id=172" method="POST" name="myform" id="myform" onSubmit="return sm_ValidateForm(this);">
		<input type="hidden" name="action" value="postnew">
		<input type="hidden" name="email_email" id="email_email" value="The email address is invalid.">
		<blockquote class="metanew">* Asterisk indicates a required field.</blockquote> 
		<table class="metanew">
		


		
		
			
			<tr style="visibility:hidden;display=none;"><td>
		
				
	
		
		
			
			
			
		
	
		
		
	
		
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	
		
		
			
			
			
		
	</td></tr>
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew"><DIV id='RecipientLabel'>Recipients</DIV>&nbsp;*<input type="hidden" name="ToEmails_required" value="You must select recipient(s) for this message.">&nbsp;</th>
				<td class="metanew">
				
						
						
						
						
						
						
						
													
						
							<select class="metanew" name="ToEmails" id="ToEmails" multiple>
							
						
						




	




		
		




 
 
 




	
	




	
	






	
	
	
	
		
		
	

	

	
	
	
		<option  value="1"> Billing </option>
	

	
	
	
		<option  value="2"> Financial Assistance </option>
	

	
	
	
		<option  value="3"> Foundation/Online Giving </option>
	

	
	
	
		<option  value="4"> Health & Wellness </option>
	

	
	
	
		<option  value="5"> Jobs </option>
	

	
	
	
		<option  value="6"> Medical Records </option>
	

	
	
	
		<option  value="12"> Pastoral Care (Chaplains) </option>
	

	
	
	
		<option  value="7"> Physician Recruitment </option>
	

	
	
	
		<option  value="8"> Physician Referral </option>
	

	
	
	
		<option  value="9"> Purchasing/Vendor Information </option>
	

	
	
	
		<option  value="10"> Web Site Questions/Feedback </option>
	

	
	
	
		<option  value="11"> Other </option>
	



 

						
							</select>
						
					
				
				</td></tr>
			
		
	
		
	
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">First Name&nbsp;*<input type="hidden" name="firstname_required" value="First name is required.">&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="firstname" id="firstname" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">Last Name&nbsp;*<input type="hidden" name="lastname_required" value="Last name is required.">&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="lastname" id="lastname" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">E-mail Address&nbsp;&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="email" id="email" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">Address&nbsp;&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="address" id="address" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">City&nbsp;&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="city" id="city" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">State&nbsp;&nbsp;</th>
				<td class="metanew">
				
						<select class="metanew" name="state" id="state"  onchange="javascript:updateslave(this)">
							<option value=""></option>
								
									
								
							
							
							





	




	
		



 





 
	
		<option  value="AK">AK</option>
	
		<option  value="AL">AL</option>
	
		<option  value="AR">AR</option>
	
		<option  value="AZ">AZ</option>
	
		<option  value="CA">CA</option>
	
		<option  value="CO">CO</option>
	
		<option  value="CT">CT</option>
	
		<option  value="DC">DC</option>
	
		<option  value="DE">DE</option>
	
		<option  value="FL">FL</option>
	
		<option  value="GA">GA</option>
	
		<option  value="HI">HI</option>
	
		<option  value="IA">IA</option>
	
		<option  value="ID">ID</option>
	
		<option  value="IL">IL</option>
	
		<option  value="IN">IN</option>
	
		<option  value="KS">KS</option>
	
		<option  value="KY">KY</option>
	
		<option  value="LA">LA</option>
	
		<option  value="MA">MA</option>
	
		<option  value="MD">MD</option>
	
		<option  value="ME">ME</option>
	
		<option  value="MI">MI</option>
	
		<option  value="MN">MN</option>
	
		<option  value="MO">MO</option>
	
		<option  value="MS">MS</option>
	
		<option  value="MT">MT</option>
	
		<option  value="NC">NC</option>
	
		<option  value="ND">ND</option>
	
		<option  value="NE">NE</option>
	
		<option  value="NH">NH</option>
	
		<option  value="NJ">NJ</option>
	
		<option  value="NM">NM</option>
	
		<option  value="NV">NV</option>
	
		<option  value="NY">NY</option>
	
		<option  value="OH">OH</option>
	
		<option  value="OK">OK</option>
	
		<option  value="OR">OR</option>
	
		<option  value="PA">PA</option>
	
		<option  value="PR">PR</option>
	
		<option  value="RI">RI</option>
	
		<option  value="SC">SC</option>
	
		<option  value="SD">SD</option>
	
		<option  value="TN">TN</option>
	
		<option  value="TX">TX</option>
	
		<option  value="UT">UT</option>
	
		<option  value="VA">VA</option>
	
		<option  value="VT">VT</option>
	
		<option  value="WA">WA</option>
	
		<option  value="WI">WI</option>
	
		<option  value="WV">WV</option>
	
		<option  value="WY">WY</option>
	
	


 

						</select>
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">Zip&nbsp;&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="zip" id="zip" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">Country&nbsp;&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="country" id="country" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">Telephone&nbsp;&nbsp;</th>
				<td class="metanew">
				
						
						
						<input class="metanew" type="text" size="40" name="telephone" id="telephone" value="" maxlength="254">
					
				
				</td></tr>
			
		
	
		
			
			
			
				
				
				
				<tr class="metanew">
				<th class="metanew">Message&nbsp;*<input type="hidden" name="comments_required" value="Your Message is required.">&nbsp;</th>
				<td class="metanew">
				
						
						
						
						<textarea class="metanew" name="comments" id="comments" rows="10" cols="40"></textarea>
					
				
				</td></tr>
			
		
	
		
	<tr style="visibility:hidden;display=none;"><td>
			
		</td></tr>
	
				<tr class="metanew">
					<th  class="metanew">Authentication&nbsp;<span class="required">*</span>&nbsp;<br><br><div align="left" style="font-weight: normal; font-size: smaller; display: inline; width:120px;">If the challenge words are too difficult to read, <a href="javascript:Recaptcha.reload();">click here</a> to refresh.</div></th>
					<td class="metanew">
			
				<input type=hidden name="recaptcha_response_field_required" value="Authentication is required."><script type="text/javascript" src="http://api.recaptcha.net/challenge?k=6LdOTwIAAAAAAFshosIOqJ9EA29aod8uED-zLmEm"></script>
				<noscript>
				   <iframe src="http://api.recaptcha.net/noscript?k=6LdOTwIAAAAAAFshosIOqJ9EA29aod8uED-zLmEm"
				       height="300" width="500" frameborder="0"></iframe><br>
				   <textarea name="recaptcha_challenge_field" rows="3" cols="40">
				   </textarea>
				   <input type="hidden" name="recaptcha_response_field" 
				       value="manual_challenge">
				</noscript>
			
					</td>
				</tr>
			
		<tr class="metanew">
			<th class="metanew">
				
			</th>
			<td class="metanew"><input class="metanew" type="submit" value="Submit" ><button class="metanew" type="button" onClick="history.go(-1)" >Cancel</button></td>
		</tr>		
		</table>		
		</form>
	
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			<!--
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