Here's the code:
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "
http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="
http://www.w3.org/1999/xhtml" xml:lang="en" lang="en">
<head>
<meta name="Description" content="Information architecture, Web Design, Web Standards." />
<meta name="Keywords" content="MH, service, equipment, hyster, yale" />
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<meta name="Distribution" content="Global" />
<meta name="Author" content="Willie Howe -
williehowe@gmail.com" />
<meta name="Robots" content="index,follow" />
<link rel="stylesheet" href="
http://resales.mhequipment.com/Refresh.css" type="text/css" />
<title>MH Equipment - ReSales</title>
<script type="text/javascript"><!--
function updatefields(){
document.getElementById('name').value = document.getElementById('mypulldown').value;
document.getElementById('email').value = document.getElementById('mypulldown').text;
}
//-->
</script>
</head>
<body>
<!-- wrap starts here -->
<div id="wrap">
<!--header -->
<div id="header">
</div>
<!-- menu -->
<div id="menu">
<font color="white"></font>
</div>
<!-- content-wrap starts here -->
<div id="content-wrap">
<div id="sidebar">
<h1>Links</h1>
<div class="left-box">
<ul class="sidemenu">
<li><a href="(%ENV_SCRIPT_NAME%)?cmd=(%HELPDESKCMD%)&sid=(%INPUT_sid%)&style=(%INPUT_style%)">[%Tickets%]</a></li>
<li>(%LOGINLOGOUT%)</li>
<li><a href="(%ENV_SCRIPT_NAME%)?cmd=newticket">[%Contact us%]</a></li>
</ul>
</div>
</div>
<div id="main">
<a name="TemplateInfo"></a>
<h1><font color="black">Ticket Request</h1></font>
<br>
<form method=post action="(%ENV_SCRIPT_NAME%)" name=newticket enctype="multipart/form-data" onsubmit="return onlyonce()">
<input type=hidden name=cmd value=newticket>
<input type=hidden name=style value="(%INPUT_style%)">
<input type=hidden name=sid value=(%INPUT_sid%)>
<input type=hidden name=do value=1>
<input type=hidden name=tid value=(%INPUT_tid%)>
<input type=hidden name=form value=(%INPUT_form%)>
<input type=hidden name=email id=email value="">
<table cellspacing=0 cellpadding=3>
<tr>
<td align=right class=lbl>[%Email%]</td>
<td align=left><select name="mypulldown" id="mypulldown" onchange="updatefields()">
<option value="Willie Howe">
whowe@mhequipment.com</option>
<option value="Justin Michels">
jmichels@mhequipment.com</option>
<option value="Mark Miller">
mmiller@mhequipment.com</option>
<option value="Steve Dahlhauser">
sdahlhauser@mhequipment.com</option>
</select></td>
</tr>
<tr>
<td align=right class-lbl>[%Name%]</td>
<td align=left><input type="text" name="name" id="name" size="32" value=""></td>
</tr>
(%CUSTOMVARS%)
(%ITEMSELSTD%)
(%OPERSELSTD%)
(%GROUPSELSTD%)
<tr>
<td align=right class=lbl>[%ReSale Manager Name%]<font color=red><sup>*</sup></font></td>
<td align=left><input type=text size=40 name=subject value="(%INPUT_subject%)"></td>
</tr>
(%KIDFORM%)
<tr>
<td colspan=2 align=center>
<table cellspacing=0 cellpadding=0>
<tr><br><br><br>
<td align=left bgcolor="#FFCC77">
<span class=lbl>[%Truck Options / Notes%]</span> <br class=tiny>
<textarea name=problem wrap=virtual cols=50 rows=10>(%INPUT_problem%)</textarea>
</td>
</tr>
</table>
</td>
</tr>
<tr><td colspan=2 align=left>(%FILEFORMS%)</td></tr>
<tr>
<td align=left>(%INTERNALCHECKBOX%)</td>
<td align=right><input type=submit value="[%Submit%]"><br><br class=tiny></td>
</tr>
</form>
</table>
</td>
</tr>
</table>
<form method="post" action="(%ENV_SCRIPT_NAME%)" id="preview" target="winpreview" >
<input type=hidden name=cmd value=preview>
<input type=hidden name=style value="(%INPUT_style%)">
<input type=hidden name=sid value=(%INPUT_sid%)>
<input type=hidden name=key value=(%INPUT_key%)>
<input type=hidden name=msg>
</form>
<br>
<font color=red><sup>*</sup></font> = Required Field
</div>
<!-- content-wrap ends here -->
</div>
<!--footer starts here-->
<div id="footer">
<p>
© 2007 <strong>MH Equipment Company</strong>
</p>
</div>
<!-- wrap ends here -->
</div>
</body>
</html>
