<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xmlns:mso="urn:schemas-microsoft-com:office:office" xmlns:msdt="uuid:C2F41010-65B3-11d1-A29F-00AA00C14882" >
<head>

    <title>request_dns</title>
    <meta http-equiv="Content-type" content="text/html; charset=UTF-8"/>

    <script type="text/javascript">

        function main() {

            var date = new Date();
            var cDate = date.getMonth() + '/' + date.getFullYear();

            //document.getElementById("00N70000002DSnX").value = cDate;
            document.getElementById("00N70000002DSnX").value = date;
            document.getElementById("rowAgencyName").style.display = "none";

            document.getElementById("rowExceptionContactTitle").style.display = "none";
            document.getElementById("rowExceptionContactFirstName").style.display = "none";
            document.getElementById("rowExceptionContactLastName").style.display = "none";
            document.getElementById("rowExceptionContactEmailAddress").style.display = "none";

            document.getElementById("00N70000002PDKj").focus();
        }

        //Check Domain Name Field
        function checkDomainNameField() {

            var domainNameValue = document.getElementById("00N70000002PDKj").value;

            if (domainNameValue == "") {
                alert("Domain Name Requested is required.");
                document.getElementById("00N70000002PDKj").focus();
                document.getElementById("00N70000002PDKj").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N70000002PDKj").style.background = 'White';

            }
        }


        // Display Exception Section
        function displayExceptionSection() {

            if (document.getElementById("00N70000002PDLD").checked == true) {
                document.getElementById("rowExceptionContactTitle").style.display = "";
                document.getElementById("rowExceptionContactFirstName").style.display = "";
                document.getElementById("rowExceptionContactLastName").style.display = "";
                document.getElementById("rowExceptionContactEmailAddress").style.display = "";
            }
            else {
                document.getElementById("rowExceptionContactTitle").style.display = "none";
                document.getElementById("rowExceptionContactFirstName").style.display = "none";
                document.getElementById("rowExceptionContactLastName").style.display = "none";
                document.getElementById("rowExceptionContactEmailAddress").style.display = "none";
            }
        }


        //Check Transition Time Line Start Date
        function checkTransitionTimeLineStartDateField() {

            var transitionTimeLineStartDateValue = document.getElementById("00N70000002PDKy").value;

            if (transitionTimeLineStartDateValue == "") {
                alert("Transition Time Line Start Date is required.");
                document.getElementById("00N70000002PDKy").focus();
                document.getElementById("00N70000002PDKy").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N70000002PDKy").style.background = 'White';

            }
        }


        //Check Transition Time Line End Date
        function checkTransitionTimeLineEndDateField() {

            var transitionTimeLineEndDateValue = document.getElementById("00N70000002PDL3").value;

            if (transitionTimeLineEndDateValue == "") {
                alert("Transition Time Line End Date is required.");
                document.getElementById("00N70000002PDL3").focus();
                document.getElementById("00N70000002PDL3").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N70000002PDL3").style.background = 'White';

            }
        }


        //Check Agency Name
        function checkAgencyNameField() {

            var agencyNameValue = document.getElementById("00N70000002PDKo").value;
            var agencyNameCustomValue = document.getElementById("00N70000002PDKt").value;

            if (agencyNameValue == null || agencyNameValue == "") {

                alert("Agency Name is required.");
                document.getElementById("00N70000002PDKo").focus();
                document.getElementById("00N70000002PDKo").style.background = 'Yellow';
            }
            else if (agencyNameValue == "NotListed" && agencyNameCustomValue == "") {
                alert("Agency Name is required.");
                document.getElementById("00N70000002PDKt").focus();
                document.getElementById("00N70000002PDKt").style.background = 'Yellow';
            }
            else {
                document.getElementById("00N70000002PDKt").style.background = 'White';
                document.getElementById("00N70000002PDKo").style.background = 'White';
            }
        }

        //Check Agency Address
        function checkAgencyAddressField() {

            var addressValue = document.getElementById("00N700000029p45").value;

            if (addressValue == null || addressValue == "") {
                alert("Agency Address is required.");
                document.getElementById("00N700000029p45").focus();
                document.getElementById("00N700000029p45").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N700000029p45").style.background = 'White';

            }
        }

        //Check Agency City
        function checkAgencyCityField() {

            var cityValue = document.getElementById("00N700000029p3h").value;

            if (cityValue == null || cityValue == "") {
                alert("Agency City is required.");
                document.getElementById("00N700000029p3h").focus();
                document.getElementById("00N700000029p3h").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N700000029p3h").style.background = 'White';

            }
        }

        //Check Agency State
        function checkAgencyStateField() {

            var stateValue = document.getElementById("00N700000029p4H").value;

            if (stateValue == null || stateValue == "") {
                alert("Agency State is required.");
                document.getElementById("00N700000029p4H").focus();
                document.getElementById("00N700000029p4H").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N700000029p4H").style.background = 'White';

            }
        }

        //Check Agency Zip Code
        function checkAgencyZipCodeField() {

            var zipCodeValue = document.getElementById("00N700000029p46").value;

            if (zipCodeValue == null || zipCodeValue == "") {
                alert("Agency Zip Code is required.");
                document.getElementById("00N700000029p46").focus();
                document.getElementById("00N700000029p46").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N700000029p46").style.background = 'White';

            }
        }


        //Check Contact First Name
        function checkAgencyContactFirstNameField() {

            var contactFirstNameValue = document.getElementById("00N70000002PFNL").value;

            if (contactFirstNameValue == null || contactFirstNameValue == "") {
                alert("Contact First Name is required.");
                document.getElementById("00N70000002PFNL").focus();
                document.getElementById("00N70000002PFNL").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N70000002PFNL").style.background = 'White';

            }
        }

        //Check Contact Last Name
        function checkAgencyContactLastNameField() {

            var contactLastNameValue = document.getElementById("00N70000002PFNC").value;

            if (contactLastNameValue == null || contactLastNameValue == "") {
                alert("Contact Last Name is required.");
                document.getElementById("00N70000002PFNC").focus();
                document.getElementById("00N70000002PFNC").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("00N70000002PFNC").style.background = 'White';

            }
        }

        //Check Contact Phone
        function checkAgencyContactPhoneField() {

            var contactPhoneValue = document.getElementById("phone").value;

            if (contactPhoneValue == null || contactPhoneValue == "") {
                alert("Contact Phone is required.");
                document.getElementById("phone").focus();
                document.getElementById("phone").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("phone").style.background = 'White';
            }
        }


        //Check Contact Email
        function checkAgencyContactEmailField() {

            var contactEmailValue = document.getElementById("email").value;

            if (contactEmailValue == null || contactEmailValue == "") {
                alert("Contact Email is required.");
                document.getElementById("email").focus();
                document.getElementById("email").style.background = 'Yellow';
                //return false;
            }
            else {
                document.getElementById("email").style.background = 'White';

            }
        }


        // Display Agency Field
        function displayAgencyField() {

            var agencyNameValue = document.getElementById("00N70000002PDKo").value;

            if (agencyNameValue == "NotListed") {
                document.getElementById("rowAgencyName").style.display = "";
                document.getElementById("00N70000002PDKt").focus();
            }
            else {
                document.getElementById("rowAgencyName").style.display = "none";
            }
        }

        function validate() {

            // Get All Values
            var thisForm = document.getElementById("frmRequestDNS");
            var domainNameValue = document.getElementById("00N70000002PDKj").value;
            var agencyNameValue = document.getElementById("00N70000002PDKo").value;
            var agencyNameCustomValue = document.getElementById("00N70000002PDKt").value;
            var dateTimeOfRequestValue = document.getElementById("00N70000002DSnX").value;
            var transitionTimeLineStartDateValue = document.getElementById("00N70000002PDKy").value;
            var transitionTimeLineEndDateValue = document.getElementById("00N70000002PDL3").value;

            var addressValue = document.getElementById("00N700000029p45").value;
            var cityValue = document.getElementById("00N700000029p3h").value;
            var stateValue = document.getElementById("00N700000029p4H").value;
            var zipCodeValue = document.getElementById("00N700000029p46").value;

            var contactFirstNameValue = document.getElementById("00N70000002PFNL").value;
            var contactLastNameValue = document.getElementById("00N70000002PFNC").value;
            var phoneValue = document.getElementById("phone").value;
            var emailValue = document.getElementById("email").value;
            var apos = emailValue.indexOf("@");
            var dotpos = emailValue.lastIndexOf(".");

            var exceptionContactFirstNameValue = document.getElementById("00N70000002PDbB").value;
            var exceptionContactLastNameValue = document.getElementById("00N70000002PDbG").value;
            var exceptionContactEmailValue = document.getElementById("00N70000002PDbL").value;
            var exceptionTitleValue = document.getElementById("00N700000029p47").value;

            // Regular Expression Validation
            var reNumber = /(^-?[1-9](\d{1,2}(\,\d{3})*|\d*)|^0{1})$/;
            //var rePhone = /^(\+\d)*\s*(\(\d{3}\)\s*)*\d{3}(-{0,1}|\{0,1})\d{2}(-{0,1}|\{0,1})\d{2}$/;
            var rePhone = /^\([1-9]\d{2}\)\s?\d{3}\-\d{4}$/; //Ex. (999) 999-9999 or (999)999-9999


            var reEmail = /^[a-zA-Z0-9._-]+@[a-zA-Z0-9.-]+\.[a-zA-Z]{2,4}$/;
            var reDate = /^\d{1,2}(\-|\/|\.)\d{1,2}\1\d{4}$/
			var reDateMMYYYY = /^\d{2}\/\d{4}$/;


            //var reDate = /^\d{1,2}\/\d{1,2}\/\d{4}$/;


            // Domain Name Requested
            if (domainNameValue == null || domainNameValue == "") {
                alert("Domain Name Requested is required.");
                document.getElementById("00N70000002PDKj").focus();
                document.getElementById("00N70000002PDKj").style.background = 'Yellow';
                return false;
            }

            // Transition Time Line Start Date
            else if (transitionTimeLineStartDateValue == null || transitionTimeLineStartDateValue == "") {
                alert("Transition Time Line Start Date is required.");
                document.getElementById("00N70000002PDKy").focus();
                document.getElementById("00N70000002PDKy").style.background = 'Yellow';
                return false;
            }

            // Transition Time Line Start Date Format
            else if (reDateMMYYYY.test(transitionTimeLineStartDateValue) == false){
                alert("Please enter a valid date in this format: mm/yyyy");
                document.getElementById("00N70000002PDKy").focus();
                return false;
            }

            // Transition Time Line End Date
            else if (transitionTimeLineEndDateValue == null || transitionTimeLineEndDateValue == "") {
                alert("Transition Time Line End Date is required.");
                document.getElementById("00N70000002PDL3").focus();
                document.getElementById("00N70000002PDL3").style.background = 'Yellow';
                return false;
            }

            // Transition Time Line Start Date Format
            else if (reDateMMYYYY.test(transitionTimeLineEndDateValue) == false){
                alert("Please enter a valid date in this format: mm/yyyy");
                document.getElementById("00N70000002PDL3").focus();
                return false;
            }


            // Agency Name
            else if (agencyNameValue == null || agencyNameValue == "") {
                alert("Agency Name is required.");
                document.getElementById("00N70000002PDKo").focus();
                document.getElementById("00N70000002PDKo").style.background = 'Yellow';
                return false;
            }

            // Agency Name Custom
            else if (agencyNameValue == "NotListed") {
                if (agencyNameCustomValue == null || agencyNameCustomValue == "") {
                    alert("Please type your Agency Name. ");
                    document.getElementById("00N70000002PDKt").focus();
                    document.getElementById("00N70000002PDKt").style.background = 'Yellow';
                    return false;
                }
            }

            // Date Time Of Request Value
            else if (dateTimeOfRequestValue == null || dateTimeOfRequestValue == "") {
                alert("Date/Time Request is required.");
                document.getElementById("00N70000002DSnX").focus();
                document.getElementById("00N70000002DSnX").style.background = 'Yellow';
                return false;
            }

            // Address
            else if (addressValue == null || addressValue == "") {
                alert("Address is required.");
                document.getElementById("00N700000029p45").focus();
                document.getElementById("00N700000029p45").style.background = 'Yellow';
                return false;
            }

            // City
            else if (cityValue == null || cityValue == "") {
                alert("City is required.");
                document.getElementById("00N700000029p3h").focus();
                document.getElementById("00N700000029p3h").style.background = 'Yellow';
                return false;
            }

            // State
            else if (stateValue == null || stateValue == "") {
                alert("State is required.");
                document.getElementById("00N700000029p4H").focus();
                document.getElementById("00N700000029p4H").style.background = 'Yellow';
                return false;
            }

            // Zip Code Value
            else if (zipCodeValue == null || zipCodeValue == "") {
                alert("Zip Code is required.");
                document.getElementById("00N700000029p46").focus();
                document.getElementById("00N700000029p46").style.background = 'Yellow';
                return false;
            }

            // Zip Code Value Required
            else if (zipCodeValue == null || zipCodeValue == "") {
                alert("Zip Code is required.");
                document.getElementById("00N700000029p46").focus();
                document.getElementById("00N700000029p46").style.background = 'Yellow';
                return false;
            }

            //Zip Code Value is 5 characters
            else if (zipCodeValue.length < 5 || zipCodeValue.length >= 6) {
                alert("Please enter Zip Code format as follows: xxxxx");
                document.getElementById("00N700000029p46").focus();
                document.getElementById("00N700000029p46").style.background = 'Yellow';
                return false;
            }

            //Zip Code Value is Numbers Only
            else if (reNumber.test(zipCodeValue) == false) {
            alert("Please enter Zip Code format as follows: xxxxx. Numbers only.");
            document.getElementById("00N700000029p46").focus();
            document.getElementById("00N700000029p46").style.background = 'Yellow';
                return false;
            }

            // Contact Name
            else if (contactNameValue == null || contactNameValue == "") {
                alert("Contact Name is required.");
                document.getElementById("name").focus();
                document.getElementById("name").style.background = 'Yellow';
                return false;
            }

            // Phone
            else if (phoneValue == null || phoneValue == "") {
                alert("Phone is required.");
                document.getElementById("phone").focus();
                document.getElementById("phone").style.background = 'Yellow';
                return false;
            }

            // Phone Format
            else if (rePhone.test(phoneValue) == false){
                alert("Please enter phone format as follows: (999)999-9999");
                document.getElementById("phone").focus();
                document.getElementById("phone").style.background = 'Yellow';
                return false;
            }

            // Email
            else if (emailValue == null || emailValue == "") {
                alert("Email is required.");
                document.getElementById("email").focus();
                document.getElementById("email").style.background = 'Yellow';
                return false;
            }
            // Email
            else if (reEmail.test(emailValue) == false) {
                alert("Please enter a valid email address.");
                document.getElementById("email").focus();
                document.getElementById("email").style.background = 'Yellow';
                return false;
            }

            // Exception Contact First Name Value
            else if (exceptionContactFirstNameValue == null || exceptionContactFirstNameValue == "") {
                alert("Exception Contact First Name is required.");
                document.getElementById("00N70000002PDbB").focus();
                document.getElementById("00N70000002PDbB").style.background = 'Yellow';
                return false;
            }

            // Exception Contact Last Name Value
            else if (exceptionContactLastNameValue == null || exceptionContactLastNameValue == "") {
                alert("Exception Contact Last Name is required.");
                document.getElementById("00N70000002PDbG").focus();
                document.getElementById("00N70000002PDbG").style.background = 'Yellow';
                return false;
            }

            // Exception Contact Email Value
            else if (exceptionContactEmailValue == null || exceptionContactEmailValue == "") {
                alert("Exception Contact Email is required.");
                document.getElementById("00N70000002PDbL").focus();
                document.getElementById("00N70000002PDbL").style.background = 'Yellow';
                return false;
            }

            // Exception Contact Email Value
            else if (exceptionTitleValue == null || exceptionTitleValue == "") {
                alert("Exception Title is required.");
                document.getElementById("00N700000029p47").focus();
                document.getElementById("00N700000029p47").style.background = 'Yellow';
                return false;
            }

            else {

                thisForm.submit();

               // window.close();


                }

            }
</script>

<style type="text/css">
@import url(http://fonts.googleapis.com/css?family=Open+Sans:400,400italic,600,600italic,700);
@import url(http://fonts.googleapis.com/css?family=Montserrat:700);

    .dialogMainContent .content {
padding:0 8px 0 0;
position:relative;
}


    .tdMiddle
    {
    	text-align:left;


    	}

    .tdRight
    {
    	text-align:left;


    	}

	.label
	{
	color: #000000;
	}
	
    .tdLeft
    {
    	text-align:right;
     	 white-space:nowrap;
         color: #000000;


		}

    .Controls
    {
	    text-align:left;
	    width:200px;



        }

        .ControlsLB
        {
        	text-align:left;
	        width:205px;


        	}

    .Table
    {
            width: 100%;
            background-color: #ffffff;
            padding:0;

        }


    .Headers {
	       	font-family: 'Montserrat', 'Open Sans', sans-serif;
        	font-size: 15px;
        	font-weight: bold;
        	font-style: normal;
        	color: #333333;
        	background-color: #f4fdff;
            border-top: 1px solid #cbcbcb;
            border-bottom: 1px solid #cbcbcb;
            line-height: 1.7;
            margin-bottom: 1em;
        }


.FontFamilyFieldsText {
font-family: 'Open Sans', sans-serif;
font-size:13px;
font-weight: 600;
color:#666666;
}
a {
    color: #007eb3;
}
input[type="submit"] {
    background: none repeat scroll 0 0 #2aaad5;
    border: 1px solid #00b8f5;
    border-radius: 4px;
    box-shadow: 0 -30px 0 -15px #0078a0 inset;
    color: #fff;
    font: bold 1.05em "open Sans";
    padding: 4px 1em;
    text-shadow: 0 0 7px #5d5d5d;
    cursor: pointer;
}



</style>

<!--[if gte mso 9]><xml>
<mso:CustomDocumentProperties>
<mso:ContentType msdt:dt="string">Document</mso:ContentType>
<mso:DocumentPublishDate msdt:dt="string">2014-11-25T00:00:00Z</mso:DocumentPublishDate>
<mso:TSLACSubject msdt:dt="string">;#Executive Departments;#Government Information;#State Governments;#</mso:TSLACSubject>
<mso:DocumentCategory msdt:dt="string">Forms</mso:DocumentCategory>
<mso:DocumentSummary msdt:dt="string">Domain Name Request Form</mso:DocumentSummary>
<mso:DIRDepartment msdt:dt="string">General</mso:DIRDepartment>
<mso:SearchKeywords msdt:dt="string"></mso:SearchKeywords>
<mso:TSLACType msdt:dt="string">Forms and Form instructions</mso:TSLACType>
<mso:DocumentExtension msdt:dt="string">htm</mso:DocumentExtension>
<mso:DocumentSize msdt:dt="string">95.427685516</mso:DocumentSize>
<mso:WorkflowChangePath msdt:dt="string">4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;4e7f0d7b-af58-4d14-a711-25a4e8942f2a,4;</mso:WorkflowChangePath>
<mso:RedirectURL msdt:dt="string">/portal/internal/resources/DocumentLibrary/request_dns.htm</mso:RedirectURL>
<mso:SearchSummary msdt:dt="string">Domain Name Request Form</mso:SearchSummary>
</mso:CustomDocumentProperties>
</xml><![endif]-->
</head>

<body onload= "javascript: return main()" class="FontFamilyFieldsText">
<form id="frmRequestDNS" name="frmRequestDNS" onsubmit="javascript: return validate()"  action="https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8" method="post">
<input type="hidden" name="recordType" id="Hidden1" value="XXXXXXXXXXXXXXX" />
<input type="hidden" name="recordType" id="recordType" value="012700000005hjU" />
<input type="hidden" name="orgid" value="00D700000008U9h" />
<input type="hidden" name="retURL" value="http://dir.texas.gov/View-Resources/request_dns_ty.html" />
<input type="hidden"  id="external" name="external" value="1" />
<!--  Testing
<input type="hidden" name="debug" value=1>
<input type="hidden" name="debugEmail" value="guillermo.irahola@dir.state.tx.us">
-->

<table class="Table" align="center" border="0" cellspacing="3" cellpadding="3">
    <tr><h1>Domain Name Registration Form<h1></tr>
    <tr>
        <td colspan="3" >To reserve a <em>texas.gov</em> domain name, complete
		and submit this form. Please review the
		<a target="_blank" href="http://publishingext.dir.texas.gov/portal/internal/resources/DocumentLibrary/Internet%20and%20Email%20Domain%20Name%20Policy.pdf">Internet and
		Email Domain Name Management Policy</a> - PDF (290 KB) before submitting this form.<br />
            <br />
            DIR will review and respond within five business days of submission.
		<br />
		<br />
		After receiving authorization for a requested domain name, a state
		agency may request delegation of that name at any time. To request the delegation of the domain, email the  <a href="mailto:DIR.Registrar@dir.texas.gov">DIR technical team</a>.
 </td>
    </tr>
    <tr>
        <td colspan="3" >&nbsp;</td>
    </tr>

    <tr>
        <td colspan="3" class="Headers">Domain Name </td>
		
    </tr>
    <tr>
        <td class="tdLeft">Domain Name Requested:</td>
        <td class="tdMiddle"><input id="00N70000002PDKj" class="Controls" maxlength="255" name="00N70000002PDKj" size="20" type="text" tabindex="1"/><label for="00N70000002PDKj">Domain name requested</label></td>
        <td>&nbsp;</td>
    </tr>

 <tr>
        <td colspan=3 align=center>
        <input  id="00N70000002PDLD" name="00N70000002PDLD" type="checkbox" onclick="displayExceptionSection();" tabindex="14"/>
		The requested domain name is an exception to the policy naming
		convention.</td>


    </tr>
     <tr id="rowExceptionContactTitle">
        <td class="tdLeft">Agency Head/Designee Title:</td>
        <td><input  id="00N700000029p47" class="Controls" maxlength="35" name="00N700000029p47" size="20" type="text" tabindex="15" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr id="rowExceptionContactFirstName">
        <td class="tdLeft">Agency Head/Designee First Name:</td>
        <td><input  id="00N70000002PDbB" class="Controls" maxlength="255" name="00N70000002PDbB" size="20" type="text" tabindex="16" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr id="rowExceptionContactLastName">
        <td class="tdLeft">Agency Head/Designee Last Name:</td>
        <td><input  id="00N70000002PDbG" class="Controls" maxlength="255" name="00N70000002PDbG" size="20" type="text" tabindex="17" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr id="rowExceptionContactEmailAddress">
        <td class="tdLeft">Agency Head/Designee Email Address:</td>
        <td><input  id="00N70000002PDbL" class="Controls" maxlength="80" name="00N70000002PDbL" size="20" type="text" tabindex="18" /></td>
        <td>&nbsp;</td>
    </tr>
       <tr>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
    </tr>


  <tr>
        <td colspan="3" class="Headers">Date and Timeline </td>
    </tr>



    <tr>
        <td class="tdLeft" nowrap="false">Date/Time of Request:</td>
        <td><input  id="00N70000002DSnX" class="Controls" name="00N70000002DSnX" size="20" type="text" readonly="readonly" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td class="tdLeft" title="Initiate planning for texas.gov transition (mm/yyyy)">Transition Timeline Start Date:</td>
        <td><input  id="00N70000002PDKy" class="Controls" name="00N70000002PDKy" size="12" type="text" tabindex="2" onfocus="checkDomainNameField();" />
        <!-- <img title="Initiate planning for texas.gov transition." src="../PublishingImages/QuoteBubble_12pxh.gif" width="26" height="20" />-->

        </td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td class="tdLeft" title="Initiate implementation of texas.gov domain (mm/yyyy)">Transition Timeline End Date:</td>
        <td><input  id="00N70000002PDL3" class="Controls" name="00N70000002PDL3" size="12" type="text" tabindex="3" onfocus="checkTransitionTimeLineStartDateField();"/>
        <!-- <img title="Initiate implementation of texas.gov domain." src="../PublishingImages/QuoteBubble_12pxh.gif" width="26" height="20" />-->

        </td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
    </tr>

    <tr>
        <td colspan="3" class="Headers"> Agency Name </td>
    </tr>
    <tr>
        <td class="tdLeft">Agency Name:</td>
        <td>
            <select  id="00N70000002PDKo" class="ControlsLB" name="00N70000002PDKo" title="Agency Name" tabindex="4" onfocus="checkTransitionTimeLineEndDateField();" onchange="displayAgencyField();">
            <option value="">-- None --</option>
            <option value="NotListed">My Agency Is Not Listed Here</option>
              <option value="Texas Military Department">Texas Military Department</option>
  <option value="Cancer Prevention and Research Institute of Texas">Cancer Prevention and Research Institute of Texas</option>
  <option value="Commission on State Emergency Communications">Commission on State Emergency Communications</option>
  <option value="Court of Appeals, Eighth District">Court of Appeals, Eighth District</option>
  <option value="Court of Appeals, Eleventh District">Court of Appeals, Eleventh District</option>
  <option value="Court of Appeals, Fifth District">Court of Appeals, Fifth District</option>
  <option value="Court of Appeals, First District">Court of Appeals, First District</option>
  <option value="Court of Appeals, Fourteenth District">Court of Appeals, Fourteenth District</option>
  <option value="Court of Appeals, Fourth District">Court of Appeals, Fourth District</option>
  <option value="Court of Appeals, Ninth District">Court of Appeals, Ninth District</option>
  <option value="Court of Appeals, Second District">Court of Appeals, Second District</option>
  <option value="Court of Appeals, Seventh District">Court of Appeals, Seventh District</option>
  <option value="Court of Appeals, Sixth District">Court of Appeals, Sixth District</option>
  <option value="Court of Appeals, Tenth District">Court of Appeals, Tenth District</option>
  <option value="Court of Appeals, Third District">Court of Appeals, Third District</option>
  <option value="Court of Appeals, Thirteenth District">Court of Appeals, Thirteenth District</option>
  <option value="Court of Appeals, Twelfth District">Court of Appeals, Twelfth District</option>
  <option value="Court of Criminal Appeals">Court of Criminal Appeals</option>
  <option value="Department of Aging and Disability Services">Department of Aging and Disability Services</option>
  <option value="Department of Assistive and Rehabilitative Services">Department of Assistive and Rehabilitative Services</option>
  <option value="Department of Family and Protective Services">Department of Family and Protective Services</option>
  <option value="Department of State Health Services">Department of State Health Services</option>
  <option value="Employees Retirement System of Texas">Employees Retirement System of Texas</option>
  <option value="Executive Council of Physical Therapy and Occupational Therapy Examiners">Executive Council of Physical Therapy and Occupational Therapy Examiners</option>
  <option value="Texas Emergency Services Retirement System">Texas Emergency Services Retirement System</option>
  <option value="Health Professions Council">Health Professions Council</option>
  <option value="Legislative Budget Board">Legislative Budget Board</option>
  <option value="Office of Capital Writs">Office of Capital Writs</option>
  <option value="Office of Consumer Credit Commissioner">Office of Consumer Credit Commissioner</option>
  <option value="Office of Court Administration">Office of Court Administration</option>
  <option value="Office of Injured Employee Counsel">Office of Injured Employee Counsel</option>
  <option value="Office of Public Insurance Counsel">Office of Public Insurance Counsel</option>
  <option value="Office of Public Utility Counsel">Office of Public Utility Counsel</option>
  <option value="Office of the Attorney General">Office of the Attorney General</option>
  <option value="Office of the Comptroller of Public Accounts">Office of the Comptroller of Public Accounts</option>
  <option value="Office of the Governor">Office of the Governor</option>
  <option value="Office of the State Prosecuting Attorney">Office of the State Prosecuting Attorney</option>
  <option value="Office of Violent Sex Offender Management">Office of Violent Sex Offender Management</option>
  <option value="Public Utility Commission of Texas">Public Utility Commission of Texas</option>
  <option value="Railroad Commission of Texas">Railroad Commission of Texas</option>
  <option value="State Auditor's Office">State Auditor's Office</option>
  <option value="State Bar of Texas">State Bar of Texas</option>
  <option value="State Commission on Judicial Conduct">State Commission on Judicial Conduct</option>
  <option value="State Office of Administrative Hearings">State Office of Administrative Hearings</option>
  <option value="State Office of Risk Management">State Office of Risk Management</option>
  <option value="State Preservation Board">State Preservation Board</option>
  <option value="Sunset Advisory Commission">Sunset Advisory Commission</option>
  <option value="Supreme Court of Texas">Supreme Court of Texas</option>
  <option value="Teacher Retirement System of Texas">Teacher Retirement System of Texas</option>
  <option value="Texas Alcoholic Beverage Commission">Texas Alcoholic Beverage Commission</option>
  <option value="Texas Animal Health Commission">Texas Animal Health Commission</option>
  <option value="Texas Board of Architectural Examiners">Texas Board of Architectural Examiners</option>
  <option value="Texas Board of Chiropractic Examiners">Texas Board of Chiropractic Examiners</option>
  <option value="Texas Board of Law Examiners">Texas Board of Law Examiners</option>
  <option value="Texas Board of Nursing">Texas Board of Nursing</option>
  <option value="Texas Board of Professional Engineers">Texas Board of Professional Engineers</option>
  <option value="Texas Board of Professional Geoscientists">Texas Board of Professional Geoscientists</option>
  <option value="Texas Board of Professional Land Surveying">Texas Board of Professional Land Surveying</option>
  <option value="Texas Bond Review Board">Texas Bond Review Board</option>
  <option value="Texas Commission on Environmental Quality">Texas Commission on Environmental Quality</option>
  <option value="Texas Commission on Fire Protection">Texas Commission on Fire Protection</option>
  <option value="Texas Commission on Jail Standards">Texas Commission on Jail Standards</option>
  <option value="Texas Commission on Law Enforcement Officer Standards and Education">Texas Commission on Law Enforcement Officer Standards and Education</option>
  <option value="Texas Commission on the Arts">Texas Commission on the Arts</option>
  <option value="Texas Credit Union Department">Texas Credit Union Department</option>
  <option value="Texas Department of Agriculture">Texas Department of Agriculture</option>
  <option value="Texas Department of Banking">Texas Department of Banking</option>
  <option value="Texas Department of Criminal Justice">Texas Department of Criminal Justice</option>
  <option value="Texas Department of Housing and Community Affairs">Texas Department of Housing and Community Affairs</option>
  <option value="Texas Department of Information Resources">Texas Department of Information Resources</option>
  <option value="Texas Department of Insurance">Texas Department of Insurance</option>
  <option value="Texas Department of Licensing and Regulation">Texas Department of Licensing and Regulation</option>
  <option value="Texas Department of Motor Vehicles">Texas Department of Motor Vehicles</option>
  <option value="Texas Department of Public Safety">Texas Department of Public Safety</option>
  <option value="Texas Department of Savings and Mortgage Lending">Texas Department of Savings and Mortgage Lending</option>
  <option value="Texas Department of Transportation">Texas Department of Transportation</option>
  <option value="Texas Education Agency">Texas Education Agency</option>
  <option value="Texas Ethics Commission">Texas Ethics Commission</option>
  <option value="Texas Facilities Commission">Texas Facilities Commission</option>
  <option value="Texas Funeral Service Commission">Texas Funeral Service Commission</option>
  <option value="Texas General Land Office">Texas General Land Office</option>
  <option value="Texas Health and Human Services Commission">Texas Health and Human Services Commission</option>
  <option value="Texas Higher Education Coordinating Board">Texas Higher Education Coordinating Board</option>
  <option value="Texas Historical Commission">Texas Historical Commission</option>
  <option value="Texas House of Representatives">Texas House of Representatives</option>
  <option value="Texas Juvenile Justice Department">Texas Juvenile Justice Department</option>
  <option value="Texas Juvenile Probation Commission">Texas Juvenile Probation Commission</option>
  <option value="Texas Legislative Council">Texas Legislative Council</option>
  <option value="Texas Legislative Reference Library">Texas Legislative Reference Library</option>
  <option value="Texas Lottery Commission">Texas Lottery Commission</option>
  <option value="Texas Medical Board">Texas Medical Board</option>
  <option value="Texas Office of State-Federal Relations">Texas Office of State-Federal Relations</option>
  <option value="Texas Optometry Board">Texas Optometry Board</option>
  <option value="Texas Parks and Wildlife Department">Texas Parks and Wildlife Department</option>
  <option value="Texas Pension Review Board">Texas Pension Review Board</option>
  <option value="Texas Public Finance Authority">Texas Public Finance Authority</option>
  <option value="Texas Racing Commission">Texas Racing Commission</option>
  <option value="Texas Real Estate Commission">Texas Real Estate Commission</option>
  <option value="Texas School for the Blind and Visually Impaired">Texas School for the Blind and Visually Impaired</option>
  <option value="Texas School for the Deaf">Texas School for the Deaf</option>
  <option value="Texas Secretary of State">Texas Secretary of State</option>
  <option value="Texas Senate">Texas Senate</option>
  <option value="Texas State Board of Dental Examiners">Texas State Board of Dental Examiners</option>
  <option value="Texas State Board of Examiners of Psychologists">Texas State Board of Examiners of Psychologists</option>
  <option value="Texas State Board of Pharmacy">Texas State Board of Pharmacy</option>
  <option value="Texas State Board of Plumbing Examiners">Texas State Board of Plumbing Examiners</option>
  <option value="Texas State Board of Podiatric Medical Examiners">Texas State Board of Podiatric Medical Examiners</option>
  <option value="Texas State Board of Public Accountancy">Texas State Board of Public Accountancy</option>
  <option value="Texas State Board of Veterinary Medical Examiners">Texas State Board of Veterinary Medical Examiners</option>
  <option value="Texas State Law Library">Texas State Law Library</option>
  <option value="Texas State Library and Archives Commission">Texas State Library and Archives Commission</option>
  <option value="Texas State Securities Board">Texas State Securities Board</option>
  <option value="Texas State Soil and Water Conservation Board">Texas State Soil and Water Conservation Board</option>
  <option value="Texas Veterans Commission">Texas Veterans Commission</option>
  <option value="Texas Water Development Board">Texas Water Development Board</option>
  <option value="Texas Workforce Commission">Texas Workforce Commission</option>

            </select></td>
            <td>&nbsp;</td>
    </tr>
    <tr id="rowAgencyName">
        <td class="tdLeft">Agency Name: </td>
        <td><input  id="00N70000002PDKt" class="Controls" maxlength="255" name="00N70000002PDKt" size="20" type="text" tabindex="5" /></td>
    </tr>

    <tr>
        <td class="tdLeft">Agency Address:</td>
        <td><input  id="00N700000029p45" class="Controls" maxlength="250" name="00N700000029p45" size="20" type="text" tabindex="6" onfocus="checkAgencyNameField();" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td class="tdLeft">Agency City:</td>
        <td><input  id="00N700000029p3h" class="Controls" maxlength="25" name="00N700000029p3h" size="20" type="text" tabindex="7" onfocus="checkAgencyAddressField();" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td class="tdLeft">Agency State:</td>
        <td><select  id="00N700000029p4H" name="00N700000029p4H" class="ControlsLB" title="State" tabindex="8" onfocus="checkAgencyCityField();">
            <option value="">-- None --</option>
            <option value="Alabama">Alabama</option>
            <option value="Alaska">Alaska</option>
            <option value="Arizona">Arizona</option>
                <option value="Arkansas">Arkansas</option>
                <option value="California">California</option>
                <option value="Colorado">Colorado</option>
                <option value="Connecticut">Connecticut</option>
                <option value="Delaware">Delaware</option>
                <option value="Florida">Florida</option>
                <option value="Georgia">Georgia</option>
                <option value="Hawaii">Hawaii</option>
                <option value="Idaho">Idaho</option>
                <option value="Illinois">Illinois</option>
                <option value="Indiana">Indiana</option>
                <option value="Iowa">Iowa</option>
                <option value="Kansas">Kansas</option>
                <option value="Kentucky">Kentucky</option>
                <option value="Louisiana">Louisiana</option>
                <option value="Maine">Maine</option>
                <option value="Maryland">Maryland</option>
                <option value="Massachusetts">Massachusetts</option>
                <option value="Michigan">Michigan</option>
                <option value="Minnesota">Minnesota</option>
                <option value="Mississippi">Mississippi</option>
                <option value="Missouri">Missouri</option>
                <option value="Montana">Montana</option>
                <option value="Nebraska">Nebraska</option>
                <option value="Nevada">Nevada</option>
                <option value="New Hampshire">New Hampshire</option>
                <option value="New Jersey">New Jersey</option>
                <option value="New Mexico">New Mexico</option>
                <option value="New York">New York</option>
                <option value="North Carolina">North Carolina</option>
                <option value="North Dakota">North Dakota</option>
                <option value="Ohio">Ohio</option>
                <option value="Oklahoma">Oklahoma</option>
                <option value="Oregon">Oregon</option>
                <option value="Pennsylvania">Pennsylvania</option>
                <option value="Rhode Island">Rhode Island</option>
                <option value="South Carolina">South Carolina</option>
                <option value="South Dakota">South Dakota</option>
                <option value="Tennessee">Tennessee</option>
                <option value="Texas" selected="selected">Texas</option>
                <option value="Utah">Utah</option>
                <option value="Vermont">Vermont</option>
                <option value="Virginia">Virginia</option>
                <option value="Washington">Washington</option>
                <option value="West Virginia">West Virginia</option>
                <option value="Wisconsin">Wisconsin</option>
                <option value="Wyoming">Wyoming</option>
                </select>
</td>
<td>&nbsp;</td>
    </tr>

    <tr>
        <td class="tdLeft">Agency Zip Code:</td>
        <td><input title="Ex: xxxxx" id="00N700000029p46" class="Controls" maxlength="10" name="00N700000029p46" size="20" type="text" tabindex="9" onfocus="checkAgencyStateField();" /></td>
        <td>&nbsp;</td>
    </tr>

    <tr>
        <td class="tdLeft">Contact First Name:</td>
        <td><input  id="00N70000002PFNL" class="Controls" maxlength="50" name="00N70000002PFNL" size="20" type="text" tabindex="10" onfocus="checkAgencyZipCodeField();" /></td>
        <td>&nbsp;</td>
    </tr>

    <tr>
        <td class="tdLeft">Contact Last Name:</td>
        <td><input  id="00N70000002PFNC" class="Controls" maxlength="50" name="00N70000002PFNC" size="20" type="text" tabindex="11" onfocus="checkAgencyContactFirstNameField();"/></td>
        <td>&nbsp;</td>
    </tr>

    <tr>
        <td class="tdLeft">Contact Phone:</td>
        <td><input title="Ex: (xxx) xxx-xxxx" id="phone" class="Controls" maxlength="40" name="phone" size="20" type="text" tabindex="12" onfocus="checkAgencyContactLastNameField();" /></td>
        <td>&nbsp;</td>
    </tr>

    <tr>
        <td class="tdLeft">Contact Email:</td>
        <td><input title="Ex: joe@schmoe.com" id="email" class="Controls" maxlength="80" name="email" size="20" type="text" tabindex="13" onfocus="checkAgencyContactPhoneField();" /></td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td class="tdLeft">&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
    </tr>
    <tr>
        <td class="tdLeft">&nbsp;</td>
        <td><input id="submit" alt="Submit" type="submit" value="  Submit  "  tabindex="19"/>
            <!-- <input id="reset" type="reset" value="   Clear   " />-->
        </td>
        <td>&nbsp;</td>
    </tr>
</table>
</form>
</body>
</html>