<form action="/index.php" method="post" onsubmit="return validateForm(this);">

<table cellspacing="0" cellpadding="0" width="100%"><tr><td width="50%" valign="top">

<table>

<tr><td colspan="2"><b>*Indicates Required Field.</b></td></tr>


<tr><td>Name* </td><td><input type="text" name="_session__firstname" value=""></td></tr>

<tr><td>Surname* </td><td><input type="text" name="_session__lastname" value=""></td></tr>

<tr><td>Company </td><td><input type="text" name="_session__company"></td></tr>

<tr><td>Address*</td><td><input type="text" name="_session__mailingaddress"></td></tr>

<tr><td>Suburb*</td><td><input type="text" name="_session__suburb"></td></tr>

<tr><td>Postcode*</td><td><input type="text" name="_session__postcode"></td></tr>

<tr><td>State*</td><td><input type="text" name="_session__state"></td></tr>

<tr><td>Country*</td><td><input type="text" name="_session__country"></td></tr>

<tr><td>Email*</td><td><input type="text" name="_session__emailaddress"></td></tr>

<tr><td>Phone*</td><td><input type="text" name="_session__phone"></td></tr>

<tr><td></td><td> <input type="checkbox" name="_session__chkcatalogue" value="Yes">&nbsp; Request Catalogue?</td></tr>

<tr><td colspan="2"><br />I am interested in:</td></tr>

<tr><td/><td><input type="checkbox" name="_session__chkproduct1" value="NORMA Products,">&nbsp;NORMA Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct2" value="Breeze Products,">&nbsp;Breeze Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct3" value="Serflex Products,">&nbsp;Serflex Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct4" value="Serratub Products,">&nbsp;Serratub Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct5" value="Terry Products,">&nbsp;Terry Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct6" value="Torca Products,">&nbsp;Torca Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct7" value="Gemi Products,">&nbsp;Gemi Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct8" value="Oetiker Products,">&nbsp;Oetiker Products</td></tr>
<tr><td/><td><input type="checkbox" name="_session__chkproduct9" value="Bandimex Products">&nbsp;Bandimex Products</td></tr>

<tr><td>Comments</td><td> <textarea name="_session__freetext" style="width:350px; height:100px"></textarea> </td></tr>
<tr><td>&nbsp;</td><td align="right" style="text-align:right"><input type="submit" value="submit"></td></tr>

</table>

</td>

<td width='50%' valign="top" style="padding-left:100px;">

<p>
<b>NORMA Pacific Pty Ltd </b><br />
85 Merrindale Drive<br />
Croydon South VIC 3136 (Australia)<br />
Tel: +61 (03) 9761 4416<br />
Fax: +61 (03) 9761 4030<br />
Email: <a href="mailto:sales.au@normagroup.com?subject=Web Enquiry">Send us an email </a>
</p>

<p>&nbsp;</p>

<p>
<b>NORMA Pacific (Thailand) Ltd</b><br />
700/709 Moo 1<br />
Amata Nakorn Industrial Estate.<br />
Tambong Phanthong, Amphur Phantong<br />
Chunburi Province 20160 Thailand<br />
Tel: +66 38 079 904 6<br />
Fax: +66 38 079 888<br />
Email: <a href="mailto:sorrasak.jeamyoungyuen@normagroup.com?subject=Web Enquiry">Send us an email </a>
</p>


<p>&nbsp;</p>

<p>
<b>NORMA Pacific (Singapore) Ltd</b><br />
No 10 Jalan Kilang #05-02<br />
Sime Darby Enterprise Centre<br />
Singapore 159410<br />
Tel: +65 6759 7955<br />
Fax: +65 6759 8092<br />
Email: <a href="mailto:fraser.ng@normagroup.com?subject=Web Enquiry">Send us an email </a>
</p>

<p>&nbsp;</p>


<p>
<b>NORMA Pacific (Asia) Pte Ltd</b><br />
Suite D 070/02<br />
Plaza Mont Kiara<br />
No.2 Jalan Kiara<br />
50480 Kuala Lumper Malaysia<br />
Tel: +65 6759 7955<br />
Fax: +65 6759 8092<br />
Email: <a href="mailto:fad.ibrahim@normagroup.com?subject=Web Enquiry">Send us an email </a>
</p>

</td></tr></table>

<input type="hidden" name="_goto" value="here">

<input type="hidden" name="_session__cuf" value="contact us form submit">

<input type="hidden" name="mandatoryfields" value="Please include the following fields;_session__firstname:Your Name;_session__lastname:Your surname;_session__mailingaddress:Your Address;_session__suburb:Your Suburb;_session__country:Your Country;_session__state:Your State;_session__postcode:Your Postcode;_session__emailaddress:Your Email;_session__phone:Your Phone Number">


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