
			<div class="contact_form_wrapper">
			<form action="../../php/formmail.php" method="post" name="form1">
			<div class="mail_form_div">
			<table class="mail_form_table">
				<tbody>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Name (First, Last):</span></td>
						<td class="mail_form_td"><input name="first_name" type="text" /><strong><span style="color:#ff0000;"><span style="font-size: 18px;">*</span></span></strong> <input name="last_name" type="text" /></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Address: </span></td>
						<td class="mail_form_td"><input id="address" name="address" size="50" type="text" /></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">&nbsp; </span></td>
						<td class="mail_form_td"><input id="address2" name="address2" size="50" type="text" /></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">City, State ZIP: </span></td>
						<td class="mail_form_td"><input id="city" name="city" type="text" /> , <select name="state" size="1"><option>-not selected-</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Dist of Columbia">Dist of Columbia</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select> <input id="zip" name="zip" size="10" type="text" /></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title" colspan="2">&nbsp;</td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Email:</span></td>
						<td class="mail_form_td"><input id="email" name="email" size="50" type="text" /><strong><span style="color:#ff0000;"><span style="font-size: 18px;">*</span></span></strong></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Email Confirm:</span></td>
						<td class="mail_form_td"><input id="email_confirm" name="email_confirm" size="50" type="text" /><strong><span style="color:#ff0000;"><span style="font-size: 18px;">*</span></span></strong></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title" colspan="2">&nbsp;&nbsp;</td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Home Phone:</span></td>
						<td class="mail_form_td"><input name="home_phone" type="text" /><input name="preferred_phone" type="radio" value="home" /><span class="mail_form_small_text"> Preferred Phone</span></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Work Phone:</span></td>
						<td class="mail_form_td"><input name="work_phone" type="text" /><input name="preferred_phone" type="radio" value="work" /><span class="mail_form_small_text"> Preferred Phone</span></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Cell Phone:</span></td>
						<td class="mail_form_td"><input name="cell_phone" type="text" /><input name="preferred_phone" type="radio" value="cell" /><span class="mail_form_small_text"> Preferred Phone</span></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Best time to call: </span></td>
						<td class="mail_form_td"><input name="best_time" type="radio" value="day" /><span class="mail_form_large_text">Day</span> <input name="best_time" type="radio" value="evening" /><span class="mail_form_large_text">Evening</span></td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title" colspan="2">&nbsp;</td>
					</tr>
					<tr>
						<td class="mail_form_td_field_title"><span class="mail_form_large_text">Message:</span></td>
						<td class="mail_form_td"><textarea cols="50" name="comments" rows="5"></textarea></td>
					</tr>
					<tr>
						<td><span style="color:#ff0000;"><strong><span style="font-size: 18px;">*</span></strong> - <span style="font-size: 10px;">Required fields</span></span></td>
						<td align="center"><input name="Submit" type="submit" value="Submit" /> <input name="redirect" type="hidden" value="/userfiles/file/contact_return.php" /> <input name="subject" type="hidden" value="Information Request" /> <input name="from" type="hidden" value="kimberly@many-blessings.com" /> <input name="recipient" type="hidden" value="kimberly+++++many-blessings.com" /> <input name="email_required" type="hidden" value="1" /> <input name="required_fields" type="hidden" value="first_name" /> <input name="html_message_page" type="hidden" value="contact_return_message" /> <input name="table_name" type="hidden" value="contact_form" />
						
						</td>
					</tr>
				</tbody>
			</table>
			</div>
			</form>
			</div>
			</div>
			<a href="http://silverdolphinsolutions.com" style="text-decoration: none;" target="_blank"><span style="color:#DFD3BD;">Designed by Silver Dolphin Solutions, LLC.</span></a> 