<form action="save-in-database18.php" method="post" name="user_details" id="user_details" onSubmit="return validateForm()">
<br>
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td><em>Check ALL that apply</em> <br /> <span class="copyPromoRed">*</span> Indicates required fields</td>
</tr>
<tr>
<td><hr></td>
</tr>
<tr>
<td><br>
How often do you shop for chocolates?</td>
</tr>
<tr>
<td> <label>
<input type="checkbox" name="How_often_shop_for_chocolates_Weekly" value="How_often_shop_for_chocolates_Weekly" id="How_often_shop_for_chocolates_Weekly">
Weekly</label>
<br>
<label>
<input type="checkbox" name="How_often_shop_for_chocolates_Monthly" value="How_often_shop_for_chocolates_Monthly" id="How_often_shop_for_chocolates_Monthly">
Monthly</label><br>
<label>
<input type="checkbox" name="How_often_shop_for_chocolates_Four_or_Less_Year" value="How_often_shop_for_chocolates_Four_or_Less_Year" id="How_often_shop_for_chocolates_Four_or_Less_Year">
Four or Less Times a Year</label>
<br>
<label>
<input type="checkbox" name="How_often_shop_for_chocolates_Holidays_Special_Occasions" value="How_often_shop_for_chocolates_Holidays_Special_Occasions" id="How_often_shop_for_chocolates_Holidays_Special_Occasions">
Holidays &amp; Special Occasions</label>
<br>
<br>
Other (please describe)
<div style="padding-left:18px;"><textarea name="How_often_shop_for_chocolates_Other" id="How_often_shop_for_chocolates_Other"></textarea></div><br>
<br>
</td>
</tr>
<tr>
<td><hr></td>
</tr>
<tr>
<td>Which type(s) of stores do you frequent?<br>
<br></td>
</tr>
<tr>
<td><div id="Which_type_of_stores_you_frequent_Traditional_Grocery_Store_checkboxgroup"><label>
<input type="checkbox" name="Which_type_of_stores_you_frequent_Traditional_Grocery_Store" value="Which_type_of_stores_you_frequent_Traditional_Grocery_Store" id="Which_type_of_stores_you_frequent_Traditional_Grocery_Store">
Traditional Grocery Store, such as Giant Eagle or Heinen's</label></div>

<div id="How_Often_Shop_at_Traditional_Grocery_Store" style="display: none">
<label>How often do you shop at this type of store?</label>
<select name="How_Often_Shop_at_Traditional_Grocery_Store" id="How_Often_Shop_at_Traditional_Grocery_Store" onchange="toggleOther( document.user_details.How_Often_Shop_at_Traditional_Grocery_Store.options[ document.user_details.How_Often_Shop_at_Traditional_Grocery_Store.selectedIndex ].value );">
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Twice_or_More_Weekly">Twice or More Weekly</option>
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Weekly">Weekly</option>
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Every_Other_Week">Every Other Week</option>
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Monthly">Monthly</option>
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Quarterly">Quarterly</option>
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Holidays_Spl_Events">Holidays &amp; Special Events, such as Summer Barbeques, Picnics</option>
<option value="How_Often_Shop_at_Traditional_Grocery_Store_Other">Other</option>
</select> <br><input type="text" name="How_Often_Shop_at_Traditional_Grocery_Store_Other_Answer" value="" size="25" maxlength="40" style="visibility:hidden" />


<br><br>Have you ever purchased chocolates at this type of store?
<select name="Have you ever purchased chocolates at this type of store?">
<option value="Have_you_purchased_chocolates_Traditional_Grocery_Store_Yes">Yes</option>
<option value="Have_you_purchased_chocolates_Traditional_Grocery_Store_No">No</option>
</select>
<br><br><br>
</div><p style="border-top:1px dashed #666666; margin-top:1em; padding-top:1em"></p>
<!--NEXT SET OF SELECTIONS -->
<div id="Which_type_of_stores_you_frequent_Warehouse_Store_checkboxgroup">
<label> <input type="checkbox" name="Which_type_of_stores_you_frequent_Warehouse_Store" value="Which_type_of_stores_you_frequent_Warehouse_Store" id="Which_type_of_stores_you_frequent_Warehouse_Store">
Warehouse Store, such as COSTCO, BJ's, or Sam's Club</label>
</div>
<p style="border-top:1px dashed #666666; margin-top:1em; padding-top:1em"></p>

<div id="How_Often_Shop_at_Warehouse_Store" style="display: none">
<label>How often do you shop at this type of store?</label>
<select name="How_Often_Shop_at_Warehouse_Store" id="How_Often_Shop_at_Warehouse_Store" onchange="toggleOther( document.user_details.How_Often_Shop_at_Warehouse_Store.options[ document.user_details.How_Often_Shop_at_Warehouse_Store.selectedIndex ].value );">
<option value="How_Often_Shop_at_Warehouse_Store_Twice_or_More_Weekly">Twice or More Weekly</option>
<option value="How_Often_Shop_at_Warehouse_Store_Weekly">Weekly</option>
<option value="How_Often_Shop_at_Warehouse_Store_Every_Other_Week">Every Other Week</option>
<option value="How_Often_Shop_at_Warehouse_Store_Monthly">Monthly</option>
<option value="How_Often_Shop_at_Warehouse_Store_Quarterly">Quarterly</option>
<option value="How_Often_Shop_at_Warehouse_Store_Holidays_Spl_Events">Holidays &amp; Special Events, such as Summer Barbeques, Picnics</option>
<option value="How_Often_Shop_at_Warehouse_Store_Other">Other</option>
</select> <br><input type="text" name="How_Often_Shop_at_Warehouse_Store_Other_Answer" value="" size="25" maxlength="40" style="visibility:hidden" />

<br><br>
Have you ever purchased chocolates at this type of store? <select name="Have you ever purchased chocolates at this type of store?">
<option value="Have_you_purchased_chocolates_Warehouse_Store_Yes">Yes</option>
<option value="Have_you_purchased_chocolates_Warehouse_Store_No">No</option>
</select>

</div>
<br>
<!--NEXT SET OF SELECTIONS -->
<div id="Which_type_of_stores_you_frequent_Specialty_Store_checkboxgroup">


<label>
<input type="checkbox" name="Which_type_of_stores_you_frequent_Specialty_Store" value="Which_type_of_stores_you_frequent_Specialty_Store" id="Which_type_of_stores_you_frequent_Specialty_Store">
Specialty Store(s), such as local produce vendors, Pat O'Brien's Fine Wines, Trader Joe's, Whole Foods</label></div>

 

<div id="How_Often_Shop_at_Specialty_Store" style="display: none">
<label>How often do you shop at this type of store?</label>
<select name="How_Often_Shop_at_Specialty_Store" id="How_Often_Shop_at_Specialty_Store" onchange="toggleOther( document.user_details.How_Often_Shop_at_Specialty_Store.options[ document.user_details.How_Often_Shop_at_Specialty_Store.selectedIndex ].value );">
<option value="How_Often_Shop_at_Specialty_Store_Twice_or_More_Weekly">Twice or More Weekly</option>
<option value="How_Often_Shop_at_Specialty_Store_Weekly">Weekly</option>
<option value="How_Often_Shop_at_Specialty_Store_Every_Other_Week">Every Other Week</option>
<option value="How_Often_Shop_at_Specialty_Store_Monthly">Monthly</option>
<option value="How_Often_Shop_at_Specialty_Store_Quarterly">Quarterly</option>
<option value="How_Often_Shop_at_Specialty_Store_Holidays_Spl_Events">Holidays &amp; Special Events, such as Summer Barbeques, Picnics</option>
<option value="How_Often_Shop_at_Specialty_Store_Other">Other</option>
</select> <br><input type="text" name="How_Often_Shop_at_Specialty_Store_Other_Answer" value="" size="25" maxlength="40" style="visibility:hidden" />

<br><br>
Have you ever purchased chocolates at this type of store? <select name="Have you ever purchased chocolates at this type of store?">
<option value="Have_you_purchased_chocolates_Specialty_Store_Yes">Yes</option>
<option value="Have_you_purchased_chocolates_Specialty_Store_No">No</option>
</select>

</div>


<p style="border-top:1px dashed #666666; margin-top:1em; padding-top:1em"></p>
Other (please describe)
<div style="padding-left:18px;">
<textarea name="Which_type_of_stores_do_you_frequent_Other" cols="30" rows="4" id="Which_type_of_stores_do_you_frequent_Other"></textarea></div><br>
<br></td>
</tr>
<tr>
<td><hr></td>
</tr>
<tr>
<td><br>
Did you know that you could purchase Mitchell's Fine Chocolates at your neighborhood Heinen's, Zagara's, or Pat O'Brien's?<br>
<br>
<select name="Did_you_know_you_could_purchase_Mitchells_at_your_neighborhood_Heinen_Zagara_PatOBrien" id="Did_you_know_you_could_purchase_Mitchells_at_your_neighborhood_Heinen_Zagara_PatOBrien">
<option value="Did_u_know_purchase_Mitchells_atHeinen_Zagara_PatOBrien_Yes">Yes</option>
<option value="Did_u_know_purchase_Mitchells_atHeinen_Zagara_PatOBrien_No">No</option>
</select>
<br>
<br></td>
</tr>
<tr>
<td><hr></td>
</tr>
<tr>
<td><br>
<br>At which of the following locations have you shopped during the last year?
<br>
<table width="438">
<tr>
<td width="181"><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Aurora" value="shopped_during_the_last_year_Heinens_of_Aurora" id="shopped_during_the_last_year_Heinens_of_Aurora">
Heinen's of Aurora</label></td>
<td width="245"><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Rocky_River" value="during_the_last_year_Heinens_of_Rocky_River" id="during_the_last_year_Heinens_of_Rocky_River">
Heinen's of Rocky River</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Avon" value="shopped_during_the_last_year_Heinens_of_Avon" id="shopped_during_the_last_year_Heinens_of_Avon">
Heinen's of Avon </label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Shaker_Hts" value="shopped_during_the_last_year_Heinens_of_Shaker_Hts" id="shopped_during_the_last_year_Heinens_of_Shaker_Hts">
Heinen's of Shaker Hts.</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Bainbridge" value="shopped_during_the_last_year_Heinens_of_Bainbridge" id="shopped_during_the_last_year_Heinens_of_Bainbridge">
Heinen's of Bainbridge</label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Strongsville" value="shopped_during_the_last_year_Heinens_of_Strongsville" id="shopped_during_the_last_year_Heinens_of_Strongsville">
Heinen's of Strongsville</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Bay_Village" value="shopped_during_the_last_year_Heinens_of_Bay_Village" id="shopped_during_the_last_year_Heinens_of_Bay_Village">
Heinen's of Bay Village </label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Twinsburg" value="shopped_during_the_last_year_Heinens_of_Twinsburg" id="shopped_during_the_last_year_Heinens_of_Twinsburg">
Heinen's of Twinsburg</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Brecksville" value="shopped_during_the_last_year_Heinens_of_Brecksville" id="shopped_during_the_last_year_Heinens_of_Brecksville">
Heinen's of Brecksville</label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_University_Hts" value="shopped_during_the_last_year_Heinens_of_University_Hts" id="shopped_during_the_last_year_Heinens_of_University_Hts">
Heinen's of University Hts.</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Chardon" value="shopped_during_the_last_year_Heinens_of_Chardon" id="shopped_during_the_last_year_Heinens_of_Chardon">
Heinen's of Chardon </label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Willoughby" value="shopped_during_the_last_year_Heinens_of_Willoughby" id="shopped_during_the_last_year_Heinens_of_Willoughby">
Heinen's of Willoughby</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Hudson" value="shopped_during_the_last_year_Heinens_of_Hudson" id="shopped_during_the_last_year_Heinens_of_Hudson">
Heinen's of Hudson</label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Mitchells_Fine_Chocolates" value="shopped_during_the_last_year_Mitchells_Fine_Chocolates" id="shopped_during_the_last_year_Mitchells_Fine_Chocolates">
Mitchell's Fine Chocolates on Lee Road</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Mayfield_Village" value="shopped_during_the_last_year_Heinens_of_Mayfield_Village" id="shopped_during_the_last_year_Heinens_of_Mayfield_Village">
Heinen's of Mayfield Village </label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Pat_OBrien" value="shopped_during_the_last_year_Heinens_of_Pat_OBrien" id="shopped_during_the_last_year_Heinens_of_Pat_OBrien">
Pat O'Brien's Fine Wines near Lander</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Mentor" value="shopped_during_the_last_year_Heinens_of_Mentor" id="shopped_during_the_last_year_Heinens_of_Mentor">
Heinen's of Mentor</label></td>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Zagara" value="shopped_during_the_last_year_Zagara" id="shopped_during_the_last_year_Zagara">
Zagara's on Lee Road</label></td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Middleburg_Hts" value="shopped_during_the_last_year_Heinens_of_Middleburg_Hts" id="shopped_during_the_last_year_Heinens_of_Middleburg_Hts">
Heinen's of Middleburg Hts. </label></td>
<td>&nbsp;</td>
</tr>
<tr>
<td><label>
<input type="checkbox" name="shopped_during_the_last_year_Heinens_of_Pepper_Pike" value="shopped_during_the_last_year_Heinens_of_Pepper_Pike" id="shopped_during_the_last_year_Heinens_of_Pepper_Pike">
Heinen's of Pepper Pike </label></td>
<td>&nbsp;</td>
</tr>
</table>
<br>
<br></td>
</tr>
<tr>
<td><hr></td>
</tr><tr>
<td>Which Mitchell's Fine Chocolates are you most interested in purchasing at a more convenient neighborhood location (small is 7 oz. or approximately 18 pieces; large is 14 oz. or approximately 36 pieces)?<br>
<br>
<p>
<label>
<input type="checkbox" name="Small_Light_Dark_Assortment" value="checkbox" id="Small_Light_Dark_Assortment ">
Small Light &amp; Dark Assortment </label>
<br>
<br>
<label>
<input type="checkbox" name="Large_Light_Dark_Assortment" value="checkbox" id="Large_Light_Dark_Assortment ">
Large Light &amp; Dark Assortment </label>
<br>
<br>
<label>
<input type="checkbox" name="Small_Dark_Assortment" value="checkbox" id="Small_Dark_Assortment">
Small Dark Assortment</label>
<br>
<br>
<label>
<input type="checkbox" name="Large_Dark_Assortment" value="checkbox" id="Large_Dark_Assortment">
Large Dark Assortment</label>
<br>
<br>
<label>
<input type="checkbox" name="Ten_oz_Approximately_15_Assorted_Truffles" value="checkbox" id="Ten_oz_Approximately_15_Assorted_Truffles">
10 oz. Approximately 15 Assorted Truffles</label>
<br>
<br>
<label>
<input type="checkbox" name="Mitchells_33_Cacao_Bar" value="checkbox" id="Mitchells_33_Cacao_Bar">
Mitchell's 33% Cacao Silky Smooth Light Chocolate Bars</label>
<br>
<br>
<label>
<input type="checkbox" name="Mitchells_52_Cacao_Bar" value="checkbox" id="Mitchells_52_Cacao_Bar">
Mitchell's 52% Cacao Signature Dark Semisweet Chocolate Bars</label>
<br>
<br>
<label>
<input type="checkbox" name="Mitchells_80_Cacao_Bar" value="checkbox" id="Mitchells_80_Cacao_Bar">
Mitchell's 80% Cacao Intense Bittersweet Chocolate Bars</label>
<br>
<br>
<label>
<input type="checkbox" name="Mitchells_Chocolate_Bark" value="checkbox" id="Mitchells_Chocolate_Bark">
Chocolate Bark</label>
<br>
<br>
<label>
<input type="checkbox" name="Pecanurtles" value="checkbox" id="Pecanurtles">
Pecanurtles</label>
<br>
<br>
<label>
<input type="checkbox" name="Chocolate_Covered_Orange_Peels" value="checkbox" id="Chocolate_Covered_Orange_Peels">
Chocolate-Covered Orange Peels</label>
<br>
<br>
<label>
<input type="checkbox" name="Chocolate_Covered_Apricots" value="checkbox" id="Chocolate_Covered_Apricots">
Chocolate-Covered Apricots</label>
<br>
<br>
<label>
<input type="checkbox" name="Salted_Caramels" value="checkbox" id="Salted_Caramels">
Salted Caramels</label>
<br>
<br>
<label>
<input type="checkbox" name="Mitchells_Marshmallows" value="checkbox" id="Mitchells_Marshmallows">
Marshmallows</label><br>
<div id="Which_Mitchells_Fine_Chocolates_are_you_most_interested_in_Other_checkboxgroup"> <label>
<input type="checkbox" name="Which_Mitchells_Fine_Chocolates_are_you_most_interested_in_Other" value="checkbox" id="Which_Mitchells_Fine_Chocolates_are_you_most_interested_in_Other">
Other </label></div><div id="Which_Mitchells_Fine_Chocolates_are_you_most_interested_in_Other_Answer" style="display: none"><textarea name="Which_Mitchells_Chocolates_most_interested_in_Other_Answer" cols="30" rows="2"></textarea></div>
<br>
</p></td>
</tr><tr>
<td><hr></td>
</tr>
</table>
<br>Thank you for completing our survey. To Receive Your FREE In-Store Gift and Enter Your Name into Our Drawing for a Gift of Assorted Chocolates, please provide your contact information here:<br><br>
<span class="copyPromoRed">*</span><span class="bodycopy"> Name</span>:
<input name="Name" type="text" id="Name" />
<br>
<br>
<span class="copyPromoRed">*</span> Email Address:
<input name="Email" type="text" id="Email" size="30" />
<br>
<br>
<input type="image" name="s1" value="Submit" src="submit.jpg" align="top" />
</form>