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www.korchek.com Open in urlscan Pro
4.227.229.192  Public Scan

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URL: https://www.korchek.com/contact-us/
Submission: On April 10 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST /contact-us/

<form action="/contact-us/" enctype="multipart/form-data" id="contactForm" method="post">
  <div class="form-horizontal">
    <div class="form-group">
      <div class="col-sm-3">
        <label for="FullName">Full Name</label>
      </div>
      <div class="col-sm-9">
        <input type="text" name="FullName" class="form-control" id="FullName" placeholder="Full Name" required="">
      </div>
    </div>
    <div class="form-group">
      <div class="col-sm-3">
        <label for="Organization">Organization Name</label>
      </div>
      <div class="col-sm-9">
        <input type="text" name="Organization" class="form-control" id="Organization" placeholder="Organization Name" required="">
      </div>
    </div>
    <div class="form-group">
      <div class="col-sm-3">
        <label for="Email">Email</label>
      </div>
      <div class="col-sm-9">
        <input type="email" name="Email" class="form-control" id="Email" placeholder="Email" required="">
      </div>
    </div>
    <div class="form-group">
      <div class="col-sm-3">
        <label for="Phone">Phone#</label>
      </div>
      <div class="col-sm-9">
        <input type="tel" name="Phone" class="form-control" id="Phone" placeholder="Phone#" required="">
      </div>
    </div>
    <div class="form-group">
      <div class="col-sm-3">
        <label for="City">City</label>
      </div>
      <div class="col-sm-9">
        <input type="text" name="City" class="form-control" id="City" placeholder="City" required="">
      </div>
    </div>
    <div class="form-group">
      <div class="col-sm-3">
        <label for="State">State</label>
      </div>
      <div class="col-sm-9">
        <select class="form-control" id="State" name="State" required="">
          <option value="">Select a State</option>
          <option value="AK">Alaska</option>
          <option value="AL">Alabama</option>
          <option value="AR">Arkansas</option>
          <option value="AZ">Arizona</option>
          <option value="CA">California</option>
          <option value="CO">Colorado</option>
          <option value="CT">Connecticut</option>
          <option value="DC">District of Columbia</option>
          <option value="DE">Delaware</option>
          <option value="FL">Florida</option>
          <option value="GA">Georgia</option>
          <option value="HI">Hawaii</option>
          <option value="IA">Iowa</option>
          <option value="ID">Idaho</option>
          <option value="IL">Illinois</option>
          <option value="IN">Indiana</option>
          <option value="KS">Kansas</option>
          <option value="KY">Kentucky</option>
          <option value="LA">Louisiana</option>
          <option value="MA">Massachusetts</option>
          <option value="MD">Maryland</option>
          <option value="ME">Maine</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="NC">North Carolina</option>
          <option value="ND">North Dakota</option>
          <option value="NE">Nebraska</option>
          <option value="NH">New Hampshire</option>
          <option value="NJ">New Jersey</option>
          <option value="NM">New Mexico</option>
          <option value="NV">Nevada</option>
          <option value="NY">New York</option>
          <option value="OH">Ohio</option>
          <option value="OK">Oklahoma</option>
          <option value="OR">Oregon</option>
          <option value="PA">Pennsylvania</option>
          <option value="PR">Puerto Rico</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="VA">Virginia</option>
          <option value="VT">Vermont</option>
          <option value="WA">Washington</option>
          <option value="WI">Wisconsin</option>
          <option value="WV">West Virginia</option>
          <option value="WY">Wyoming</option>
          <option value="XX">Other</option>
        </select>
      </div>
    </div>
    <div class="form-group">
      <div class="col-sm-3">
        <label for="Message">Message</label>
      </div>
      <div class="col-sm-9">
        <textarea type="text" rows="5" name="Message" class="form-control" id="Message" required=""></textarea>
      </div>
    </div>
    <div class="col-md-9 col-md-offset-3">
      <button type="submit" class="btn btn-danger btn-block hide">Submit</button>
      <div id="recaptcha" class="g-recaptcha" name="ReCaptcha" data-sitekey="6LfB9icUAAAAAJUenbxfrlBEPPporFt1l5MqXc95" data-callback="enableSubmit" data-expired-callback="disableSubmit">
        <div style="width: 304px; height: 78px;">
          <div><iframe title="reCAPTCHA"
              src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LfB9icUAAAAAJUenbxfrlBEPPporFt1l5MqXc95&amp;co=aHR0cHM6Ly93d3cua29yY2hlay5jb206NDQz&amp;hl=de&amp;v=6MY32oPwFCn9SUKWt8czDsDw&amp;size=normal&amp;cb=g7eed9yudi0x" width="304"
              height="78" role="presentation" name="a-nzgn8g76qzop" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"
              data-lf-form-tracking-inspected-ywvko4x6jm18z6bj="true" data-lf-yt-playback-inspected-ywvko4x6jm18z6bj="true" data-lf-vimeo-playback-inspected-ywvko4x6jm18z6bj="true"></iframe></div><textarea id="g-recaptcha-response"
            name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
        </div><iframe data-lf-form-tracking-inspected-ywvko4x6jm18z6bj="true" data-lf-yt-playback-inspected-ywvko4x6jm18z6bj="true" data-lf-vimeo-playback-inspected-ywvko4x6jm18z6bj="true" style="display: none;"></iframe>
      </div>
    </div>
  </div>
  <input name="ufprt" type="hidden"
    value="D24B8D9BFEBD211321F9DCDC002198309BF9622D1CB19699FB0BF19D20BA2EA90BBCE54D771F907E597A8F565F3DFB50A013B250A1EF08E0469850602B5ED006FD855FC9F77FD184478FB6C1069680D5A0A5DABC4F2E85BFC01E19DFDFC4739D09E1B1C41584BF2FBDA99117EDEFDFBD1FFDEB533C9B3DCE95D3FA52342D4E6DBF0A3014E7C88C84D8696CAB6EEDC506E114F51120E462BF94CA1A20872443A1">
</form>

Text Content

 * Products
   * Implementation Services
   * Bedside Barcoding
   * Data Migration & Archiving
 * About Us
 * Contact Us
 * Blog
 * Events



--------------------------------------------------------------------------------


CONTACT US

--------------------------------------------------------------------------------


SEND AN EMAIL

Full Name

Organization Name

Email

Phone#

City

State
Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut
District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana
Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota
Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire
New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto
Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia
Vermont Washington Wisconsin West Virginia Wyoming Other
Message

Submit



OUR INFO

Korchek Technologies

115 Technology Drive, Suite B206

Trumbull, CT 06611

T. 877.KOR.CHEK (567.2435)

T. 203.452.8295

F. 203.452.8296

Contact Us
 * Korchek Technologies
 * 115 Technology Drive Suite B206
 * Trumbull, CT 06611

 * T. 877.KOR.CHEK (567.2435)
 * T. 203.452.8295
 * F. 203.452.8296

Products
 * Implementation Services
 * Bedside Barcoding
 * Data Migration & Archiving

Social Media
 * Twitter
 * Facebook
 * LinkedIn