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Name*:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Promo Code*:</td><td><input type=\"text\" name=\"custom State\" value=\"99999\" size=\"20\"></td></tr><tr><td>Address:</td><td><input type=\"text\" name=\"custom Address\" value=\"\" size=\"20\"></td></tr><tr><td>City State and Zip:</td><td><input type=\"text\" name=\"custom City\" value=\"\" size=\"20\"></td></tr><tr><td>Home and Work Phone:</td><td><input type=\"text\" name=\"custom Home Phone\" value=\"\" size=\"20\"></td></tr><tr><td>Mobile Phone:</td><td><input type=\"text\" name=\"custom Mobil Phone\" value=\"\" size=\"20\"></td></tr><tr><td>Address (Property):</td><td><input type=\"text\" name=\"custom Property Address\" value=\"\" size=\"20\"></td></tr><tr><td>City (Property):</td><td><input type=\"text\" name=\"custom City (Property)\" value=\"\" size=\"20\"></td></tr><tr><td>State (Property):</td><td><input type=\"text\" name=\"custom State (Property)\" value=\"\" size=\"20\"></td></tr><tr><td>Zip Code (Property):</td><td><input type=\"text\" name=\"custom Zip Code (Property)\" value=\"\" size=\"20\"></td></tr><tr><td>County:</td><td><input type=\"text\" name=\"custom County\" value=\"\" size=\"20\"></td></tr><tr><td>Property Type:</td><td><select name=\"custom Property Type\"><option value=\"Single Family\">Single Family</option><option value=\"Condo\">Condo</option><option value=\"Town Home\">Town Home</option><option value=\"Duplex\">Duplex</option><option value=\"Triplex\">Triplex</option><option value=\"Quad\">Quad</option><option value=\"5+ Apartment\">5+ Apartment</option><option value=\"Mobil in Park\">Mobil in Park</option><option value=\"Mobil W/ Land\">Mobil W/ Land</option><option value=\"Modular\">Modular</option><option value=\"Commercial\">Commercial</option><option value=\"Land\">Land</option><option value=\"Other\">Other</option></select></td></tr><tr><td>Number of Bedrooms:</td><td><input type=\"text\" name=\"custom Number of Bedrooms\" value=\"\" size=\"20\"></td></tr><tr><td>Number of Bathrooms:</td><td><input type=\"text\" name=\"custom Number of Bathrooms\" value=\"\" size=\"20\"></td></tr><tr><td>Number of Stories:</td><td><input type=\"text\" name=\"custom Number of Stories\" value=\"\" size=\"20\"></td></tr><tr><td>Square Feet:</td><td><input type=\"text\" name=\"custom Zip Code\" value=\"\" size=\"20\"></td></tr><tr><td>Year Built:</td><td><input type=\"text\" name=\"custom Work Phone\" value=\"\" size=\"20\"></td></tr><tr><td>Garage Spaces:</td><td><input type=\"text\" name=\"custom Garage Spaces\" value=\"\" size=\"20\"></td></tr><tr><td>Current Value:</td><td><input type=\"text\" name=\"custom Current Value\" value=\"\" size=\"20\"></td></tr><tr><td>Why are you Selling:</td><td><input type=\"text\" name=\"custom Garage Type\" value=\"\" size=\"20\"></td></tr><tr><td colspan=\"2\" align=\"left\">Are you in Foreclosure:</td></tr><tr><td colspan=\"2\"><input type=\"radio\" name=\"custom Are you in 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size=\"20\"></td></tr>    <tr><td colspan=2><center><div>The more information we have the better we can make an evaluation to purchase the property.</div></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Buy My Property Now\"></td></tr></table></form></center>");

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