Feedback

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<form enctype=”multipart/form-data” method=”post” action=”http://www.response-o-matic.com/mail.php” accept-charset=”UTF-8″>
<div>
<input type=”hidden” name=”acctid” id=”acctid” value=”3w2ywfmkyhvjk3yl” />
<input type=”hidden” name=”formid” id=”formid” value=”1300913″ />
<input type=”hidden” name=”required_vars” id=”required_vars” value=”name,email,field-5e7b679576e7761,field-b382fccb23e0663″ />
</div>
<table cellspacing=”5″ cellpadding=”5″ border=”0″>
<tr>
<td valign=”top”>
<strong>Name:</strong>
</td>
<td valign=”top”>
<input type=”text” name=”name” id=”name” size=”40″ value=”” />

</td>
</tr>
<tr>
<td valign=”top”>
<strong>Email Address:</strong>
</td>
<td valign=”top”>
<input type=”text” name=”email” id=”email” size=”40″ value=”” />

</td>
</tr>
<tr>
<td valign=”top”>
<strong>Mobile contact</strong>
</td>
<td valign=”top”>
<input type=”text” name=”field-5e7b679576e7761″ id=”field-5e7b679576e7761″ size=”40″ value=”” />

</td>
</tr>
<tr>
<td valign=”top”>
<strong>Address</strong>
</td>
<td valign=”top”>
<textarea name=”field-b382fccb23e0663″ id=”field-b382fccb23e0663″ rows=”6″ cols=”40″></textarea>

</td>
</tr>
<tr>
<td colspan=”2″ align=”center”>
<input type=”submit” value=” Submit Form ” />
</td>
</tr>
</table>
</form>
<br><center><font face=”Arial, Helvetica” size=”1″><b>
<a href=”http://www.response-o-matic.com”>Click here</a> to create your own form.
</b></font></center>
<!– End Response-O-Matic Form –>