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52 lines
2.4 KiB
52 lines
2.4 KiB
<?php // info request input form
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?>
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<table border=0 cellpadding=2 cellspacing=0>
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<form method="post" action="reply.php3">
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<tr>
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<td><input type="checkbox" name="general" value="send">General Info.</td>
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<td><input type="checkbox" name="business" value="send">Business Info.</td>
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<td><input type="checkbox" name="realestate" value="send">Real Estate</td>
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<td><input type="checkbox" name="schools" value="send">Schools</td></tr>
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<tr>
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<td><input type="checkbox" name="history" value="send">Historical Info.</td>
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<td><input type="checkbox" name="rental" value="send">Rental Property</td>
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<td><input type="checkbox" name="tourism" value="send">Tourist Info.</td>
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<td><input type="checkbox" name="cityhall" value="send">City Hall Info.</td></tr>
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<tr>
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<td><input type="checkbox" name="other" value="send">Other Info.</td>
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<td><input type="checkbox" name="maps" value="send">Area Maps</td>
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<td><input type="checkbox" name="ind_parks" value="send">Industrial Parks</td>
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<td><input type="checkbox" name="membership" value="send">Membership Info.</td></tr>
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<tr><td colspan=4>  </td></tr>
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</table>
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<table><tr><td>
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<table border=0 cellpadding=2 cellspacing=0>
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<tr><td class=label>Name:</td>
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<td class=data><input type="text" name="name" size=20 maxlength=20></td>
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<tr><td class=label>Address:</td>
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<td class=data><input type="text" name="address" size=20 maxlength=20></td>
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<tr><td class=label>City:</td>
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<td class=data><input type="text" name="city" size=20 maxlength=20></td>
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<tr><td class=label>State:</td>
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<td class=data><input type="text" name="state" size=20 maxlength=20></td>
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<tr><td class=label>Zip:</td>
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<td class=data><input type="text" name="zip" size=20 maxlength=20></td>
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</table>
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</td><td>
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<table border=0 cellpadding=2 cellspacing=0>
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<tr><td class=label>Title:</td>
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<td class=data><input type="text" name="title" size=20 maxlength=20></td></tr>
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<tr><td class=label>Company:</td>
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<td class=data><input type="text" name="company" size=20 maxlength=20></td></tr>
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<tr><td class=label>Phone:</td>
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<td class=data><input type="text" name="phone" size=20 maxlength=20></td></tr>
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<tr><td class=label>Fax:</td>
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<td class=data><input type="text" name="fax" size=20 maxlength=20></td></tr>
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<tr><td class=label>Email:</td>
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<td class=data><input type="text" name="email" size=20 maxlength=40></td></tr>
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</table>
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</td></tr></table>
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<table border=0 cellpadding=2 cellspacing=0>
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<tr><td colspan=4 class=dropped>
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<input type="reset"><input type="submit"></td></tr>
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</table>
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