<?xml version="1.0" encoding="UTF-8"?>

<form url="debtform10.php"
 window="_self"
 method="POST"
 fontname="MS Sans Serif"
 width="308"
 height="313"
 bkcolor="0xFFFFFF"
 transparent="f"
 fontcolor="0x000000"
 outlinecolor="0xFFFFFF"
 themecolor="0xFF9900"
 fontcolor2="#000000"
 bkcolor2="#FFFFFF"
 includeresults="false"
 emailuser="false"
 verifymessage="The E-Mail address you entered does not match !"
 reqmessage="Phone number and Email are Required !"
 transition="0"
 autoresponseincluderesults="f"
 autoresponseaddtotop="f"
 usephp="true"
 disableclicktoactiveprompt="true"
 extensions="*.txt;*.gif;*.jpg;*.jpeg;*.zip;*.doc;*.png;*.pdf;*.rtf"
>

<hidden
 name="thankyoupage"
 value="http://www.thedebtstore.com/thankyou.html"
></hidden>

<hidden
 name="subject"
 value="Lead From The Debt Store"
></hidden>

<textinput
 name="first_name"
 x="124"
 y="12"
 w="143"
 h="22"
 initvalue=""
 maxchars="25"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 editable="true"
>
</textinput>

<textinput
 name="last_name"
 x="124"
 y="56"
 w="143"
 h="22"
 initvalue=""
 maxchars="25"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 editable="true"
>
</textinput>

<textinput
 name="phone_1"
 x="124"
 y="100"
 w="40"
 h="22"
 initvalue=""
 maxchars="3"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
  restrict="num"
>
</textinput>

<textinput
 name="phone_2"
 x="168"
 y="100"
 w="40"
 h="22"
 initvalue=""
 maxchars="3"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
  restrict="num"
>
</textinput>

<textinput
 name="phone_3"
 x="212"
 y="100"
 w="55"
 h="22"
 initvalue=""
 maxchars="4"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
  restrict="num"
>
</textinput>

<textinput
 name="email"
 x="124"
 y="144"
 w="166"
 h="22"
 initvalue=""
 maxchars="25"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 emailbox="true"
 editable="true"
  restrict="email"
>
</textinput>

<combobox
 name="unsecured_debt"
 x="124"
 y="184"
 bkcolor="0xFFFFFF"
 fontcolor="0x000000"
 isemail="false"
 w="152"
 h="20">
  <item name="$0 -   $9,999"></item>
  <item name="$10,000 -   $14,999"></item>
  <item name="$10,000 - $19,999"></item>
  <item name="$20,000 - $29,999"></item>
  <item name="$30,000 -   $39,999"></item>
  <item name="$40,000 - $49,999"></item>
  <item name="$50,000 - $59,999"></item>
  <item name="$60,000 -   $69,999"></item>
  <item name="$70,000 - $79,999"></item>
  <item name="$80,000 - $89,999"></item>
  <item name="$90,000 -   $99,999"></item>
  <item name="$100,000+"></item>
</combobox>

<combobox
 name="state"
 x="124"
 y="228"
 bkcolor="0xFFFFFF"
 fontcolor="0x000000"
 isemail="false"
 w="100"
 h="20">
  <item name="Select One:"></item>
  <item name="Alabama"></item>
  <item name="Alaska"></item>
  <item name="Arizona"></item>
  <item name="Arkansas"></item>
  <item name="California"></item>
  <item name="Colorado"></item>
  <item name="Connecticut"></item>
  <item name="Delaware"></item>
  <item name="Florida"></item>
  <item name="Georgia"></item>
  <item name="Hawaii"></item>
  <item name="Idaho"></item>
  <item name="Illinois"></item>
  <item name="Indiana"></item>
  <item name="Iowa"></item>
  <item name="Kansas"></item>
  <item name="Kentucky"></item>
  <item name="Louisiana"></item>
  <item name="Maine"></item>
  <item name="Maryland"></item>
  <item name="Massachusetts"></item>
  <item name="Michigan"></item>
  <item name="Minnesota"></item>
  <item name="Mississippi"></item>
  <item name="Missouri"></item>
  <item name="Montana"></item>
  <item name="Nebraska"></item>
  <item name="Nevada"></item>
  <item name="New Hampshire"></item>
  <item name="New Jersey"></item>
  <item name="New Mexico"></item>
  <item name="New York"></item>
  <item name="North Carolina"></item>
  <item name="North Dakota"></item>
  <item name="Ohio"></item>
  <item name="Oklahoma"></item>
  <item name="Oregon"></item>
  <item name="Pennsylvania"></item>
  <item name="Rhode Island"></item>
  <item name="South Carolina"></item>
  <item name="South Dakota"></item>
  <item name="Tennessee"></item>
  <item name="Texas"></item>
  <item name="Utah"></item>
  <item name="Vermont"></item>
  <item name="Virginia"></item>
  <item name="Washington"></item>
  <item name="West Virginia"></item>
  <item name="Wisconsin"></item>
  <item name="Wyoming"></item>
</combobox>

<submitbutton
 name="Submit Button"
 x="40"
 y="268"
 w="231"
 h="40"
 label="Submit"
 fontname="Arial"
 fontcolor="0x000000"
 image="quotebutton2.jpg"
  fontsize="12"
></submitbutton>

<label
 name="My Text 1"
 x="36"
 y="16"
 w="83"
 h="13"
 text="First Name :"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x333333"
  fontsize="11"
></label>

<label
 name="My Text 2"
 x="40"
 y="60"
 w="80"
 h="13"
 text="Last Name :"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x333333"
  fontsize="11"
></label>

<label
 name="My Text 4"
 x="12"
 y="104"
 w="107"
 h="13"
 text="Phone Number :"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x333333"
  fontsize="11"
></label>

<label
 name="My Text 5"
 x="72"
 y="148"
 w="48"
 h="13"
 text="Email :"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x333333"
  fontsize="11"
></label>

<label
 name="My Text 7"
 x="4"
 y="188"
 w="115"
 h="13"
 text="Unsecured Debt :"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x333333"
  fontsize="11"
></label>

<label
 name="My Text 8"
 x="68"
 y="232"
 w="46"
 h="13"
 text="State :"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x333333"
  fontsize="11"
></label>

</form>