Custom New Offer Request form

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<h2>Offer Request</h2>

<form id="form1" method="POST">
<p><b>To request an offer please fill out the form below:</b></p>

<p><label>First Name:</label> <input id="or_fname" maxlength="30" name="or_fname" size="30" type="text" value="" /></p>

<p><label>Last Name:</label> <input id="or_lname" maxlength="30" name="or_lname" size="30" type="text" value="" /></p>

<p><label>Owner's First Name:</label> <input id="o_fname" maxlength="30" name="o_fname" size="30" type="text" value="" /></p>

<p><label>Owner's Last Name:</label> <input id="o_lname" maxlength="30" name="o_lname" size="30" type="text" value="" /></p>

<p><b>Is there someone else on title?</b></p>

<p><label>2nd Owner's First Name:</label> <input id="o_2fname" maxlength="30" name="o_2fname" size="30" type="text" value="" /></p>

<p><label>2nd Owner's Last Name:</label> <input id="o_2lname" maxlength="30" name="o_2lname" size="30" type="text" value="" /></p>

<p><label>2nd 3rd Owner's First Name:</label> <input id="o_3fname" maxlength="30" name="o_3fname" size="30" type="text" value="" /></p>

<p><label>Company Name:</label> <input id="o_company" maxlength="30" name="o_company" size="80" type="text" value="" /></p>

<p><label>What is a good phone number that we can reach you at if we have any additional questions in the future?</label> <input id="or_phone" maxlength="30" name="or_phone" placeholder="Phone number..." size="30" type="text" value="" /></p>

<p><label>Do you have an email address that you use frequently?</label> <input id="or_email" maxlength="100" name="or_email" placeholder="Email..." size="100" type="email" value="" /></p>

<p><b>What is a good mailing address for you?</b></p>

<p><label>Mailing Address:</label> <input id="m_address" name="m_address" size="30" type="text" value="" /></p>

<p><label>Mailing Address 2:</label> <input id="m_address2" name="m_address2" size="30" type="text" value="" /></p>

<p><label>Mailing City:</label> <input id="m_city" name="m_city" size="30" type="text" value="" /></p>

<p><label>Mailing State:</label> <select id="m_state" name="m_state"><option value="">Select One...</option><option disabled="disabled" value="disabled1">-----States-----</option><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District Of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</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="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option><option disabled="disabled" value="disabled2">-----Territories-----</option><option value="AS">American Samoa</option><option value="GU">Guam</option><option value="MP">Northern Mariana Islands</option><option value="VI">U.S. Virgin Islands</option><option value="UM">U.S. Minor Outlying Islands</option><option disabled="disabled" value="disabled3">-----Freely Associated States-----</option><option value="FM">Micronesia</option><option value="MH">Marshall Islands</option><option value="PW">Palau</option><option disabled="disabled" value="disabled4">-----Canada Provinces-----</option><option value="AB">Alberta</option><option value="BC">British Columbia</option><option value="MB">Manitoba</option><option value="NB">New Brunswick</option><option value="NL">Newfoundland and Labrador</option><option value="NS">Nova Scotia</option><option value="ON">Ontario</option><option value="PE">Prince Edward Island</option><option value="QC">Quebec</option><option value="SK">Saskatchewan</option><option disabled="disabled" value="disabled5">-----Canada Territories-----</option><option value="NT">Northwest Territories</option><option value="YT">Yukon</option><option value="NU">Nunavut</option> </select></p>

<p><label>Zip Code:</label> <input id="m_zip" name="m_zip" size="30" type="text" value="" /></p>

<p><b>Property Information</b></p>

<p><label>APN (Parcel Number):</label> <input id="p_apn" maxlength="30" name="p_apn" size="30" type="text" value="" /></p>

<p><label>Property State:</label> <select id="p_state" name="p_state"><option value="">Select One...</option><option disabled="disabled" value="disabled1">-----States-----</option><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District Of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</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="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option><option disabled="disabled" value="disabled2">-----Territories-----</option><option value="AS">American Samoa</option><option value="GU">Guam</option><option value="MP">Northern Mariana Islands</option><option value="VI">U.S. Virgin Islands</option><option value="UM">U.S. Minor Outlying Islands</option><option disabled="disabled" value="disabled3">-----Freely Associated States-----</option><option value="FM">Micronesia</option><option value="MH">Marshall Islands</option><option value="PW">Palau</option><option disabled="disabled" value="disabled4">-----Canada Provinces-----</option><option value="AB">Alberta</option><option value="BC">British Columbia</option><option value="MB">Manitoba</option><option value="NB">New Brunswick</option><option value="NL">Newfoundland and Labrador</option><option value="NS">Nova Scotia</option><option value="ON">Ontario</option><option value="PE">Prince Edward Island</option><option value="QC">Quebec</option><option value="SK">Saskatchewan</option><option disabled="disabled" value="disabled5">-----Canada Territories-----</option><option value="NT">Northwest Territories</option><option value="YT">Yukon</option><option value="NU">Nunavut</option> </select></p>

<p><label>Property County:</label> <input id="p_county" maxlength="50" name="p_county" size="30" type="text" value="" /></p>

<p><label>Property Zip:</label> <input id="p_zip" maxlength="50" name="p_zip" size="30" type="text" value="" /></p>

<p><label>Property Address:</label> <input id="p_address" maxlength="50" name="p_address" size="30" type="text" value="" /></p>

<p><label>Property Size (In Acres):</label> <input id="p_acres" maxlength="30" name="p_acres" size="30" type="text" value="" /></p>

<p><label>Property Size (In SQ.FT)</label> <input id="p_sqft" maxlength="30" name="p_sqft" size="30" type="text" value="" /></p>

<p><label>Is there an HOA/POA in this area?</label> <input id="p_hoa" maxlength="30" name="p_hoa" size="30" type="text" value="" /></p>

<p><label>Loan/Mortgage or Lien:</label> <input id="p_liens" maxlength="100" name="p_liens" placeholder="$" value="" /></p>

<p><label>Back Taxes:</label> <input id="p_backtaxes" maxlength="100" name="p_backtaxes" placeholder="$" value="" /></p>

<p><b>Are there any improvements on the property?:</b></p>

<table>
	<tbody>
		<tr>
			<td>Cabin</td>
			<td><input id="house" name="house" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>Shed</td>
			<td><input id="shed" name="shed" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>Mobile Home</td>
			<td><input id="mobile_home" name="mobile_home" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>RV Hookup</td>
			<td><input id="rv_hookup" name="rv_hookup" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>Septic System</td>
			<td><input id="septic_system" name="septic_system" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>Well</td>
			<td><input id="well" name="well" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>Fence</td>
			<td><input id="fence" name="fence" type="checkbox" value="Y" /></td>
		</tr>
		<tr>
			<td>Other:</td>
			<td><input id="other" name="other" type="text" value="" /></td>
		</tr>
	</tbody>
</table>

<p><label>Is there electricity to the property?</label> <select id="p_power" name="p_power"><option value="">Select One...</option><option value="Yes">Yes</option><option value="Within 1/4 of a mile">Within 1/4 of a mile</option><option value="Within 1 mile">Within 1 mile</option><option value="No">No</option> </select></p>

<p><label>Does the property have road access?</label> <select id="p_access" name="p_access"><option value="">Select One...</option><option value="Yes - Paved">Yes - Paved</option><option value="Yes - Unpaved">Yes - Unpaved</option><option value="Legal and Physical Access">Legal and Physical Access</option><option value="Legal Access Only">Legal Access Only</option><option value="Physical Access Only">Physical Access Only</option><option value="Easement">Easement</option><option value="No">No</option> </select></p>

<p><label>How did you acquire this property?</label> <select id="p_aquired" name="p_aquired"><option value="">Select One...</option><option value="Purchased">Purchased</option><option value="Inherited">Inherited</option><option value="Gifted">Gifted</option><option value="Probate Needed">Probate Needed</option> </select></p>

<p><label>How long have you owned the property?</label> <select id="p_owned" name="p_owned"><option value="">Select One...</option><option value="0">&lt;1 Year</option><option value="1">1-3 Years</option><option value="3">3-5 Years</option><option value="5">5-10 Years</option><option value="10">10-15 Years</option><option value="15">15-20 Years</option><option value="20">20-30 Years</option><option value="30">&gt;30 Years</option> </select></p>

<p><label>If we can pay cash and close on any date you want, what would be the least that you would take for the property?</label> <input id="p_min_acceptable_offer" maxlength="30" name="p_min_acceptable_offer" onkeypress="return onlyNumbers(this, event)" placeholder="$" size="10" type="text" value="" /></p>

<p><label>Seller Agent's Name or Company:</label> <input id="p_seller_agent_name" maxlength="30" name="p_seller_agent_name" size="30" type="text" value="" /></p>

<p><label>Seller Agent's Phone Number:</label> <input id="p_seller_agent_phone" maxlength="30" name="p_seller_agent_phone" size="30" type="text" value="" /></p>

<p><label>Call Notes:</label><br />
<textarea id="p_comments" name="p_comments" rows="5"></textarea></p>

<p><b>At this point we will need to complete some detailed research on your property. Once the research has been finalized we will mail you a no-obligation written offer within 7-10 business days, so you have something official in writing that you can review. Thank you very much for your call and you will be hearing from us soon.</b></p>
<input type="submit" value="Request Offer Now" />
</form>
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