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<!DOCTYPE html> <html lang="en"> <head><script src="/Sprighter-a-newly-of-my-Louer-Entermittlemaine-I" async></script> <meta http-equiv="X-UA-Compatible" content="IE=edge" /> <meta http-equiv="Content-Type" content="text/html;charset=utf-8" > <meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0"> <title>DOH Feedback</title> <link rel="canonical" href="https://www.nj.gov/health/feedback.shtml" /> <meta name="keywords" content=' feedback, comments, suggestions, DOH, health, NJ '/> <meta name="description" content='DOH Feedback' /> <meta name="modified" content='03/28/2024' /> <meta name="editor" content='qru' /> <link rel="stylesheet" href="/nj/design/bootstrap/css/bootstrap.min.css" />  <link href="/nj/design/css/sonj-components.css?v=2022.04.06" rel="stylesheet" type="text/css" /> <link href="/nj/design/css/site-base.css?v=2022.04.06" rel="stylesheet" type="text/css" /> <link rel="stylesheet" type="text/css" href="/nj/design/util/slick/slick.css" /> <link rel="stylesheet" type="text/css" href="/nj/design/util/slick/slick-theme.css" />   <script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-P3V3PJ6');</script>   <link rel="stylesheet" type="text/css" href="/health/assets/css/doh-responsive-styles.css?v=2023.12.20"> </head> <body data-pnav="" id="dept-health" class="siteTheme-blue"> <div class="skip"><a href="#content">Skip to Content</a></div> <h1 class="sr-only">Healthy New Jersey</h1> <header class="sonj "> <div class="container-fluid"> <div class="row justify-content-center"> <div id="logo" class="col-sm-8 col-lg-5 col-xl-5"> <h1 class="my-2"><img src="/nj/design/images/state_seal_white.png" alt="State of New Jersey Seal" title="">Official Site of The State of New Jersey</h1> </div> <div class=" col-sm-4 col-lg-5 col-xl-5"> <div class="gov-bar text-right d-none d-lg-block"><a href="https://nj.gov/governor/" target="_blank">Governor Phil Murphy • Lt. 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data-pnav="placeholder-legal"><a class="nav-link " href="https://nj.gov/health/legal/" data-sNav_scalar="0" >Legal and Regulatory Compliance</a> </li> </ul> </div> </nav> </div> </div> </div> <div class="skip"><a name="content"></a></div>  <div class="container-fluid "> <div class="row justify-content-center mt-3 mb-5"> <div class="col col-xl-10"> <nav aria-label="breadcrumb"> <ol class="breadcrumb mb-0"> <li class="breadcrumb-item"><a href="/health/">Home</a></li> <li class="breadcrumb-item active" aria-current="page">DOH Feedback</li> </ol> </nav> <h2 class="mt-5 pageTitle">DOH Feedback</h2> </div> </div> </div> <main> <div class="container-fluid "> <div class="row justify-content-center my-5"> <div class="col-12 col-xl-10"> <section> <p>The Department of Health offers several ways to communicate with our site visitors.</p> </section> <section> <h3 class="sectionTitle x-h5 " id="heading_0">Send Comments / Request Information </h3> <div id='section_0' class='' aria-labelledby='heading_0' aria-expanded=''> <p>Feel free to send your comments, suggestions, and/or questions. We value your input and desire to make these pages as useful as possible.</p> <table border="1" width="98%" cellspacing="0" cellpadding="4" align="center" bgcolor="#ffffcc"> <tbody> <tr> <td> <div align="center">Please do not submit personal information, such as<strong> social security numbers, detailed medical history or similar personal information </strong>via this "Contact Us" form. If we need additional information, we will contact you.</div> </td> </tr> </tbody> </table> <p>In the form below, select the Office or Recipient that you want to send your message to. If you are unsure of which office should receive your message, select General Feedback.</p> <form action="/cgi-bin/dhss/contact/dhssmail.pl" method="post" name="form"> <table style="height: 634px;" border="0" width="680" cellspacing="0" cellpadding="3"> <tbody> <tr style="height: 18px;"> <td style="height: 18px; width: 670px;" colspan="2" valign="top"><span style="color: #ff6600;"><strong>*</strong></span>required information.</td> </tr> <tr style="height: 18px;"> <td style="height: 18px; width: 120.797px;"> </td> <td style="height: 18px; width: 541.203px;" valign="top"> </td> </tr> <tr style="height: 19px;"> <td style="height: 19px; width: 120.797px;" align="right"> <div align="left"><span style="color: #ff6600;"><strong>*</strong></span>Program: </div> </td> <td style="height: 19px; width: 541.203px;"><select name="recipient"> <option selected="selected" value="">(select one)</option> <option value="General Feedback">General Feedback</option> <option value="Birth, Marriage and Death Certificates">Birth, Marriage and Death Certificates</option> <option value="">Cancer (Select one of the cancer programs)</option> <option value="Cancer Control">      Cancer Control</option> <option value="Cancer Data and Cancer Registry">      Cancer Data and Cancer Registry</option> <option value="Cancer Donations">      Cancer Donations</option> <option value="Cancer Screening">      Cancer Screening</option> <option value="Cancer Epidemiology Services">      Cancer Epidemiology Services</option> <option value="NJ Cancer Education and Early Detection">      NJ Cancer Education and Early Detection</option> <option value="NJ Commission on Cancer Research">      NJ Commission on Cancer Research</option> <option value="Office of Cancer Control and Prevention">      Office of Cancer Control and Prevention</option> <option value="Epidemiology, Environmental & Occupational Health">Epidemiology, Environmental & Occupational Health</option> <option value="Emergency Medical Services">Emergency Medical Services</option> <option value="Ethics Liason Officer">Ethics Liason Officer</option> <option value="Family Health Services">Family Health Services</option> <option value="Division of Certificate of Need and Licensing">Division of Certificate of Need and Licensing</option> <option value="HIV/AIDS Services">HIV/AIDS Services</option> <option value="Hospital Performance Report">Hospital Performance Report</option> <option value="Health Facility Survey and Field Operations">Health Facility Survey and Field Operations</option> <option value="Minority and Multicultural Health">Minority and Multicultural Health</option> <option value="Newborn Screening">Newborn Screening</option> <option value="NJ Commission on Brain Injury Research">NJ Commission on Brain Injury Research</option> <option value="Post-Polio Syndrome">Post-Polio Syndrome</option> <option value="Public Health & Environmental Laboratories">Public Health & Environmental Laboratories</option> <option value="Quality Information for Health Care Professionals">Quality Information for Health Care Professionals</option> <option value="Data: Birth, Death, Injury, and Behavioral Risk Factors">Statistics: Birth, Death, Injury, and Behavioral Risk Factors</option> </select></td> </tr> <tr style="height: 19px;" valign="top"> <td style="height: 19px; width: 120.797px;" align="right"> <div align="left">Prefix: </div> </td> <td style="height: 19px; width: 541.203px;" align="left"><select name="prefix"> <option selected="selected" value=""></option> <option value="Captain">Captain</option> <option value="Chief">Chief</option> <option value="Councilman">Councilman</option> <option value="Councilwoman">Councilwoman</option> <option value="Dame">Dame</option> <option value="Doctor">Doctor</option> <option value="Dr.">Dr.</option> <option value="Dr. and Mr.">Dr. and Mr.</option> <option value="Dr. and Mrs.">Dr. and Mrs.</option> <option value="Father">Father</option> <option value="Friend">Friend</option> <option value="Friends">Friends</option> <option value="Miss">Miss</option> <option value="Monsignor">Monsignor</option> <option value="Mr.">Mr.</option> <option value="Mr. and Mrs.">Mr. and Mrs.</option> <option value="Mrs.">Mrs.</option> <option value="Ms.">Ms.</option> <option value="Pastor">Pastor</option> <option value="Rabbi">Rabbi</option> <option value="Rev.">Rev.</option> <option value="Reverend">Reverend</option> <option value="Sir">Sir</option> <option value="Sister">Sister</option> <option value="The Honorable">The Honorable</option> </select></td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">First Name: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input id="first" maxlength="25" name="first" size="25" type="text" value="" /></td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">Middle Initial: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input id="mi" maxlength="1" name="mi" size="1" type="text" /></td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">Last Name: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input id="last" maxlength="25" name="last" size="25" type="text" /></td> </tr> <tr style="height: 19px;" valign="top"> <td style="height: 19px; width: 120.797px;" align="right"> <div align="left">Suffix: </div> </td> <td style="height: 19px; width: 541.203px;" align="left"><select name="suffix"> <option></option> <option value="Esq.">Esq.</option> <option value="Jr.">Jr.</option> <option value="Sr.">Sr.</option> <option value="Ph.D.">Ph.D.</option> <option value="MD">MD</option> <option value="D.V.M.">D.V.M.</option> <option value="D.D.S.">D.D.S.</option> <option value="R.N.">R.N.</option> <option value="III">III</option> <option value="II">II</option> <option value="L.L.D.">L.L.D.</option> <option value="M.B.A.">M.B.A.</option> <option value="Family">Family</option> </select></td> </tr> <tr style="height: 18px;" valign="top"> <td style="height: 18px; width: 120.797px;" align="right"> <div align="left">Address: </div> </td> <td style="height: 18px; width: 541.203px;" align="left"> </td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">Street: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input maxlength="50" name="address" size="50" type="text" value="" /></td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">Suite/P.O. Box: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input maxlength="50" name="po" size="50" type="text" /></td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">City: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input id="city" maxlength="50" name="city" size="50" type="text" value="" /></td> </tr> <tr style="height: 19px;"> <td style="height: 19px; width: 120.797px;" align="right"> <div align="left">county:</div> </td> <td style="height: 19px; width: 541.203px;" align="left"><select name="county"> <option value=""></option> <option value="Atlantic">Atlantic</option> <option value="Bergen">Bergen</option> <option value="Burlington">Burlington</option> <option value="Camden">Camden</option> <option value="Cape May">Cape May</option> <option value="Cumberland">Cumberland</option> <option value="Essex">Essex</option> <option value="Gloucester">Gloucester</option> <option value="Hudson">Hudson</option> <option value="Hunterdon">Hunterdon</option> <option value="Mercer">Mercer</option> <option value="Middlesex">Middlesex</option> <option value="Monmouth">Monmouth</option> <option value="Morris">Morris</option> <option value="Ocean">Ocean</option> <option value="Passaic">Passaic</option> <option value="Salem">Salem</option> <option value="Somerset">Somerset</option> <option value="Sussex">Sussex</option> <option value="Union">Union</option> <option value="Warren">Warren</option> </select></td> </tr> <tr style="height: 19px;" valign="top"> <td style="height: 19px; width: 120.797px;" align="right"> <div align="left">state:</div> </td> <td style="height: 19px; width: 541.203px;" align="left"><select id="state" name="state"> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DC">Dist. of Col.</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MO">Missouri</option> <option value="MS">Mississippi</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option selected="selected" value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> <option value="AS">American Samoa</option> <option value="FM">Fed. States Micronesia</option> <option value="GU">Guam</option> <option value="MH">Marshall Islands</option> <option value="MP">North Mariana Is.</option> <option value="PR">Puerto Rico</option> <option value="VI">Virgin Islands</option> </select></td> </tr> <tr style="height: 21px;" valign="top"> <td style="height: 21px; width: 120.797px;" align="right"> <div align="left">Zip Code: </div> </td> <td style="height: 21px; width: 541.203px;" align="left"><input id="zip2" maxlength="5" name="zip" size="5" type="text" /> - <input id="zipplus" maxlength="4" name="zipplus" size="4" type="text" /></td> </tr> <tr style="height: 19px;" valign="top"> <td style="height: 19px; width: 120.797px;" align="right"> <div align="left">Country: </div> </td> <td style="height: 19px; width: 541.203px;" align="left"><select name="country"> <option value="AF">Afghanistan</option> <option value="AL">Albania</option> <option value="DZ">Algeria</option> <option value="AS">American Samoa</option> <option value="AD">Andorra</option> <option value="AO">Angola</option> <option value="AI">Anguilla</option> <option value="AQ">Antarctica</option> <option value="AG">Antigua and Barbuda</option> <option value="AR">Argentina</option> <option value="AM">Armenia</option> <option value="AW">Aruba</option> <option value="AU">Australia</option> <option value="AT">Austria</option> <option value="AZ">Azerbaijan</option> <option value="BS">Bahamas</option> <option value="BH">Bahrain</option> <option value="BD">Bangladesh</option> <option value="BB">Barbados</option> <option value="BY">Belaras</option> <option value="BE">Belgium</option> <option value="BZ">Belize</option> <option value="BJ">Benin</option> <option value="BM">Bermuda</option> <option value="BT">Bhutan"</option> <option value="BO">Bolivia</option> <option value="BA">Bosnia and Herzegovina</option> <option value="BW">Botswana</option> <option value="BV">Bouvet Island</option> <option value="BR">Brazil</option> <option value="IO">Bristish Indian Open Territory</option> <option value="BN">Brunei Darussalam</option> <option value="BG">Bulgaria</option> <option value="BF">Burkina Faso</option> <option value="BI">Burundi</option> <option value="KH">Cambodia</option> <option value="CM">Cameroon</option> <option value="CA">Canada</option> <option value="CV">Cape Verde</option> <option value="KY">Cayman Islands</option> <option value="CF">Central African Republic</option> <option value="TD">Chad</option> <option value="CL">Chile</option> <option value="CN">Chin</option> <option value="CX">Christmas Island</option> <option value="CC">Cocos (Keeling Islands)</option> <option value="CO">Columbia</option> <option value="KM">Comoros</option> <option value="CG">Congo</option> <option value="CK">Cook Islands</option> <option value="CR">Costa Rica</option> <option value="CI">Cote D'Ivoire (Ivory Coast)</option> <option value="HR">Crotia (Hrvatska)</option> <option value="CU">Cuba</option> <option value="CY">Cyprus</option> <option value="CZ">Czech Republic</option> <option value="DK">Denmark</option> <option value="DJ">Djibouti</option> <option value="DM">Dominica</option> <option value="DO">Dominican Republic</option> <option value="TP">East Timor</option> <option value="EC">Ecudor</option> <option value="EG">Egypt</option> <option value="SV">El Salvador</option> <option value="GQ">Equitorial Guinea</option> <option value="ER">Eritrea</option> <option value="EE">Estonia</option> <option value="ET">Ethiopia</option> <option value="FO">Faroe Islands</option> <option value="FK">Faulkland Islands</option> <option value="FJ">Fiji</option> <option value="FI">Finland</option> <option value="FR">France</option> <option value="FX">France, Metropolitan</option> <option value="GF">French Guiana</option> <option value="PF">French Polynesia</option> <option value="TF">French Southern Territories</option> <option value="GA">Gabon</option> <option value="GM">Gambia</option> <option value="GE">Georgia</option> <option value="DE">Germany</option> <option value="GH">Ghana</option> <option value="GI">Gibraltar</option> <option value="GR">Greece</option> <option value="GL">Greenland</option> <option value="GD">Grenada</option> <option value="GP">Guadeloupe</option> <option value="GU">Guam</option> <option value="GT">Guatemala</option> <option value="GN">Guinea</option> <option value="GW">Guinea-Bissau</option> <option value="GY">Guyana</option> <option value="HT">Haiti</option> <option value="HM">Heard and McDonald Islands</option> <option value="HN">Honduras</option> <option value="HK">Hong Kong</option> <option value="HU">Hungary</option> <option value="IS">Iceland</option> <option value="ZW">Zimbabwe</option> <option value="IN">India</option> <option value="ID">Indonesia</option> <option value="IR">Iran</option> <option value="IQ">Iraq</option> <option value="IE">Ireland</option> <option value="IL">Israel</option> <option value="IT">Italy</option> <option value="JM">Jamaica</option> <option value="JP">Japan</option> <option value="JO">Jordan</option> <option value="KZ">Kazakhstan</option> <option value="KE">Kenya</option> <option value="KI">Kiribati</option> <option value="KP">Korea (North)</option> <option value="KR">Korea (South)</option> <option value="KW">Kuwait</option> <option value="KG">Kyrgyzstan</option> <option value="LA">Laos</option> <option value="LV">Latvia</option> <option value="LB">Lebenon</option> <option value="LS">Lesotho</option> <option value="LR">Liberia</option> <option value="LY">Libya</option> <option value="LI">Liechtenstein</option> <option value="LT">Lithuania</option> <option value="LU">Luxembourg</option> <option value="MO">Macau</option> <option value="MK">Macedonia</option> <option value="MG">Madagascar</option> <option value="MW">Malawi</option> <option value="MY">Malaysia</option> <option value="MV">Maldives</option> <option value="ML">Mali</option> <option value="MT">Malta</option> <option value="MA">Marroco</option> <option value="MH">Marshall Islands</option> <option value="MQ">Martinique</option> <option value="MR">Mauritania</option> <option value="MU">Mauritius</option> <option value="YT">Mayotte</option> <option value="MX">Mexico</option> <option value="FM">Micronesia</option> <option value="MD">Moldova</option> <option value="MC">Monaco</option> <option value="MN">Mongolia</option> <option value="MS">Montserrat</option> <option value="MZ">Mozambique</option> <option value="MM">Myanmar</option> <option value="NA">Namibia</option> <option value="NR">Nauru</option> <option value="NP">Nepal</option> <option value="NL">Netherlands</option> <option value="AN">Netherlands Antilles</option> <option value="NC">New Caledonia</option> <option value="NZ">New Zealand</option> <option value="NI">Nicaragua</option> <option value="NE">Niger</option> <option value="NG">Nigeria</option> <option value="NU">Niue</option> <option value="NF">Norfolk Island</option> <option value="MP">Northern Mariana Islands</option> <option value="NO">Norway</option> <option value="OM">Oman</option> <option value="PK">Pakistan</option> <option value="PW">Palau</option> <option value="PA">Panama</option> <option value="PG">Papua New Guinea</option> <option value="PY">Paraguay</option> <option value="PE">Peru</option> <option value="PH">Philippines</option> <option value="PN">Pitcairn</option> <option value="PL">Poland</option> <option value="PT">Portugal</option> <option value="PR">Puerto Rico</option> <option value="QA">Qatar</option> <option value="RE">Reunion</option> <option value="RO">Romania</option> <option value="RU">Russian Federation</option> <option value="RW">Rwanda</option> <option value="GS">S. Georgia\S. Sandwich Isls.</option> <option value="KN">Saint Kitts and Nevis</option> <option value="LC">Saint Lucia</option> <option value="VC">Saint Vincent\The Grenadines</option> <option value="WS">Samoa</option> <option value="SM">San Marino</option> <option value="ST">Sao Tome and Principe</option> <option value="SA">Saudi Arabia</option> <option value="SN">Senegal</option> <option value="SC">Seychelles</option> <option value="SL">Sierra Leone</option> <option value="SG">Singapore</option> <option value="SK">Slovak Republic</option> <option value="SI">Slovenia</option> <option value="SB">Soloman Islands</option> <option value="SO">Somalia</option> <option value="ZA">South Africa</option> <option value="ES">Spain</option> <option value="LK">Sri Lanka</option> <option value="SH">St. Helena</option> <option value="PM">St. Pierre and Miquelon</option> <option value="SD">Sudan</option> <option value="SR">Suriname</option> <option value="SJ">Svalbard and Jan Mayen Islands</option> <option value="SZ">Swaziland</option> <option value="SE">Sweden</option> <option value="CH">Switzerland</option> <option value="SY">Syria</option> <option value="TW">Taiwan</option> <option value="TJ">Tajikistan</option> <option value="TZ">Tanzania</option> <option value="TH">Thailand</option> <option value="TG">Togo</option> <option value="TK">Tokelau</option> <option value="TO">Tonga</option> <option value="TT">Trinidad and Tobago</option> <option value="TN">Tunisia</option> <option value="TR">Turkey</option> <option value="TM">Turkmenistan</option> <option value="TC">Turks and Caicos Islands</option> <option value="TV">Tuvalu</option> <option value="UG">Uganda</option> <option value="UA">Ukraine</option> <option value="AE">United Arab Emirates</option> <option value="UK">United Kingdom</option> <option selected="selected" value="US">United States</option> <option value="UY">Uraguay</option> <option value="UM">US Minor Outlying Islands</option> <option value="UZ">Uzbekistan</option> <option value="VU">Vanuatu</option> <option value="VA">Vatican City State</option> <option value="VE">Venezuela</option> <option value="VN">Viet Nam</option> <option value="VG">Virgin Islands (British)</option> <option value="VI">Virgin Islands (US)</option> <option value="WF">Wallis and Futana Islands</option> <option value="EH">Western Sahara</option> <option value="YE">Yeman</option> <option value="YU">Yugoslavia</option> <option value="ZR">Zaire</option> <option value="ZM">Zambia</option> </select></td> </tr> <tr style="height: 39px;" valign="top"> <td style="height: 39px; width: 120.797px;" align="right"> <div align="left"><span style="color: #ff6600;">*</span>Phone Number:</div> </td> <td style="height: 39px; width: 541.203px;" align="left">( <input maxlength="3" name="phone1" size="3" type="text" value="" />) <input maxlength="3" name="phone2" size="3" type="text" /> - <input maxlength="4" name="phone3" size="4" type="text" /> ext <input maxlength="5" name="ext" size="5" type="text" />   Phone number OR email address is required.</td> </tr> <tr style="height: 39px;" valign="top"> <td style="height: 39px; width: 120.797px;" align="right"> <div align="left"><span style="color: #ff6600;">*</span>E-mail:</div> </td> <td style="height: 39px; width: 541.203px;" align="left"><input maxlength="100" name="email_1" size="50" type="text" value="" />   Phone number OR email address is required.</td> </tr> <tr style="height: 36px;" valign="top"> <td style="height: 36px; width: 120.797px;" align="right"> <div align="left">Re-enter E-mail: </div> </td> <td style="height: 36px; 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