../public_html/includes/templates/template_default/templates/tpl_request_demo_default.php
Code:
<?php
//
// +----------------------------------------------------------------------+
// |zen-cart Open Source E-commerce                   |
// +----------------------------------------------------------------------+
// | Copyright © 2003 The zen-cart developers             |
// |                                   |
// | http://www.zen-cart.com/index.php                  |
// |                                   |
// | Portions Copyright © 2003 osCommerce               |
// +----------------------------------------------------------------------+
// | This source file is subject to version 2.0 of the GPL license,   |
// | that is bundled with this package in the file LICENSE, and is    |
// | available through the world-wide-web at the following url:     |
// | http://www.zen-cart.com/license/2_0.txt.              |
// | If you did not receive a copy of the zen-cart license and are unable |
// | to obtain it through the world-wide-web, please send a note to   |
// | license AT zen-cart DOT com so we can mail you a copy immediately.     |
// +----------------------------------------------------------------------+
// $Id: tpl_request_demo_default.php,v 1.0 2015/05/13 00:00:00 Avenview Exp $
//
?>

<STYLE>
BODY
{scrollbar-face-color: #528607; scrollbar-shadow-color: #3B6201; 
scrollbar-highlight-color: #639E0C; scrollbar-3dlight-color: #7BB625; 
scrollbar-darkshadow-color: #2C4901; scrollbar-track-color: #3F6A01; 
scrollbar-arrow-color: #D8FA2E}
</STYLE>
<?php echo zen_draw_form('request_demo', zen_href_link(FILENAME_REQUEST_DEMO, 'action=send')); ?>
<div><h1><?php echo HEADING_TITLE; ?></h1></div> 
<table width="100%" border="0" cellspacing="2" cellpadding="2" >
<?php
 if ($messageStack->size('request_demo') > 0) {
?>
<?php
 }

 if (isset($_GET['action']) && ($_GET['action'] == 'success')) {
?>
 <tr>
  <td class="plainBox" colspan="2"><?php echo TEXT_SUCCESS; ?></td>
 </tr>
 <tr>
  <td class="main" colspan="2"><?php echo zen_back_link() . zen_image_button(BUTTON_IMAGE_BACK, BUTTON_BACK_ALT) . '</a>'; ?></td>
 </tr>
<?php
 } else {
?>
<tr>
  <td class="plainBoxHeading" colspan="2" valign="top" style="border-top:0px; border-bottom:0px; border-left:3px solid #ED1D26; background:#e1e1e1; color:#555;">Demo Request:</td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Product:<font color="#FF0000">*</font></td>
  <td class="main" valign="top"><select name="rad_product" style="width: 150px;">
<option value="">Please Select One</option>
<option value="Video Walls">Video Walls</option>
<option value="Multi Viewers">Multi Viewers</option>
<option value="Video Matrix Switches">Video Matrix Switches</option>
</select></td>
</tr>
<tr>
  <td class="plainBoxHeading" colspan="2" valign="top" style="border-top:0px; border-bottom:0px; border-left:3px solid #ED1D26; background:#e1e1e1; color:#555;">Customer Information:</td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Full Name:<font color="#FF0000">*</font></td>
  <td class="main" valign="top"><input type="text" name="rad_fullname"  style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Company:</td>
  <td class="main" valign="top"><input type="text" name="rad_company" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Email:<font color="#FF0000">*</font></td>
  <td class="main" valign="top"><?php echo zen_draw_input_field('rad_email', ($error ? $_POST['rad_email'] : $email), ' size="10"'); ?></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Phone:<font color="#FF0000">*</font></td>
  <td class="main" valign="top"><input type="text" name="rad_phone" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Address:</td>
  <td class="main" valign="top"><input type="text" name="rad_address1" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Address (optional):</td>
  <td class="main" valign="top"><input type="text" name="rad_address2" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">City:</td>
  <td class="main" valign="top"><input type="text" name="rad_city" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Postal Code/Zip Code:</td>
  <td class="main" valign="top"><input type="text" name="rad_postal" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">State/Province:</td>
  <td class="main" valign="top"><input type="text" name="rad_state" style="width: 150px;"></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Country:</td>
  <td class="main" valign="top"><select name="rad_country" style="width: 150px;">
	<option value="United States" title="United States">United States</option>
	<option value="Afghanistan" title="Afghanistan">Afghanistan</option>
	<option value="Åland Islands" title="Åland Islands">Åland Islands</option>
	<option value="Albania" title="Albania">Albania</option>
</select></td>
</tr>
<tr>
  <td class="plainBoxHeading" align="right" valign="top" width="100">Comments (optional):</td>
  <td class="main" valign="top"><?php echo zen_draw_textarea_field('comments', '45', '10', ''); ?></td>
</tr>
<tr>
  <td class="main" colspan="2" align="right" valign="top">I have read and agree to the <a target="popup" onclick="window.open('index.php?main_page=conditions','name','width=600,height=400')">user agreement</a>:<font color="#FF0000">*</font>
   <input type="checkbox" name="termsandconds" value="1"></td>
</tr>
 <tr>
  <td class="main" colspan="2"><?php echo $messageStack->output('request_demo'); ?></td>
 </tr>
<!--START CAPTCHA INPUT HERE -->

<?php
if (ACCOUNT_VALIDATION == 'true' && REQUEST_DEMO_VALIDATION == 'true') {
?>

<?php
if (strstr($_SERVER['REQUEST_URI'],'request_demo') && REQUEST_DEMO_VALIDATION == 'true' || strstr($_SERVER['REQUEST_URI'],'login') && LOGIN_VALIDATION == 'true') { 
?>

<?php
  if ($is_read_only == false || (strstr($_SERVER['REQUEST_URI'],'contact_us')) || (strstr($_SERVER['REQUEST_URI'],'login'))) {
    $sql = "DELETE FROM " . TABLE_ANTI_ROBOT_REGISTRATION . " WHERE timestamp < '" . (time() - 3600) . "' OR session_id = '" . zen_session_id() . "'";
    if( !$result = $db->Execute($sql) ) { die('Could not delete validation key'); }
    $reg_key = generate_captcha_code();
    $sql = "INSERT INTO ". TABLE_ANTI_ROBOT_REGISTRATION . " VALUES ('" . zen_session_id() . "', '" . $reg_key . "', '" . time() . "')";
    if( !$result = $db->Execute($sql) ) { die('Could not check registration information'); }
?>
<tr>
  <td class="main" colspan="3" align="right" valign="top">
<legend><?php echo CATEGORY_ANTIROBOTREG; ?></legend>
<?php if ($messageStack->size('request_demo') > 0) echo $messageStack->output('request_demo_validation'); ?>
<?php
$validation_images = '';
for($i = 0; $i < ENTRY_VALIDATION_LENGTH; $i++)
    {
    $parse_image = 'validation/validation_' . $reg_key{$i} . '.gif';
    $parse_image_alt = $reg_key{$i};
    $validation_images .= zen_image(DIR_WS_IMAGES . $parse_image, $parse_image_alt);
    }
    echo '<div class="centered">';
    echo $validation_images . '<br />';
    echo '</div>';
?>


<?php echo zen_draw_input_field('antirobotreg','', 'id="antirobotreg"') . (zen_not_null(ENTRY_ANTIROBOTREG) ? '<span class="alert">' . ENTRY_ANTIROBOTREG_TEXT . '</span>': ''); ?>
<br class="clearBoth" />

<?php
    }
?>

<?php
    }
?>

<?php
    }
?>
<!-- END CAPTCHA INPUT -->
</td></tr>
<tr>
  <td><?php echo zen_back_link() . zen_image_button(BUTTON_IMAGE_BACK, BUTTON_BACK_ALT) . '</a>'; ?></td>
  <td><?php echo zen_image_submit('button_send.gif', REQUEST_DEMO); ?></td>
 </tr>
<?php
 }
?>
</table></form>