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<HTML>
<HEAD>
<TITLE>Request for more information</TITLE>
</HEAD>
<BODY>
<form action="http://www.bigplanet.com/cgi-bin/thank_you.pl" method="POST">
<input type="hidden" name="Subject" value="Information Request"><input type="hidden" name="Recipient" value="[email protected]">
<!-- Submissions are emailed to: -->
<input type="hidden" name="to"
value="[email protected]">
<!-- Subject of emails: -->
<input type="hidden" name="subject"
value="Info Request">
<!-- URL (web address) of form: -->
<input type="hidden" name="form"
value="http://www.jaworldconnect.com">
<!-- Form administrator: -->
<input type="hidden" name="admin"
value="[email protected]">
<!-- Visible elements: -->
<center><img src="http://dwp.bigplanet.com/bradleyfloors/nss-folder/pictures/1logo.jpg" alt="MJ Bradley Company, Inc."></center>
<font face="arial","helvetica" size="2">
<center><h2>Request for More Information</h2></center>
<font size="4">Please provide us with the following so that we may better serve you:</font><p>
<!-- INSERT ADDITIONAL FORM FIELDS HERE: -->
Your Company:
<input name="company" size=50><p>
Your full name:
<input name="name" size=40><br>
<!-- Take email addresses with a grain of salt! -->
Your email address: (e.g.: <em>[email protected]</em>)
<input name="from" size=30><p>
Your phone number (xxx-xxx-xxxx):
<input name="phone" size=15><BR>
Your fax number (xxx-xxx-xxxx):
<input name="fax" size=15><p>
<table border=0>
<tr><td align="right" valign="top"><font face="arial","helvetica" size="2">Address:</font></td>
<td align="left"><input name="address1" size=50><br>
<input name="address2" size=50></td></tr>
<tr><td align="right" valign="top"><font face="arial","helvetica" size="2">City/Town:</font></td>
<td align="left"><input name="city" size=20>
<font face="arial","helvetica" size="2">State/Prov.:</font><input name="state" size=2>
<font face="arial","helvetica" size="2">Post./Zip Code:</font><input name="zip" size=10></td></tr>
<tr><td align="right" valign="top"><font face="arial","helvetica" size="2">Country:</font></td>
<td align="left"><input name="country" size=10></td></tr>
</table>
<p>
Type of Facility
<input name="facility"
size=35><br>
Type of Area
<input name="area"
size=35><br>
Approximate Size of Area (Total Square Feet)
<input name="size"
size=20><br>
Existing Floor Surface
<input name="surface"
size=35><br>
How soon will work need to be completed?:<br>
<input type="checkbox" name="ASAP"
value="selected"> ASAP
<input type="checkbox" name="1MONTH"
value="selected"> 1 Month
<br> <input type="checkbox" name="3MONTH"
value="selected"> 3 Months
<br> <input type="checkbox" name="6MONTH"
value="selected">6 Months
<input type="checkbox" name="1YEAR"
value="selected">1 Year
<br>
<!-- Open question (response will not be indented): -->
Location of Project (Town,County,State)?...<br>
<textarea name="Projectlocation"
rows=3 cols=55 wrap="VIRTUAL"></textarea><p>
<!-- Open question (response will not be indented): -->
Additional comments/questions? ...<br>
<textarea name="Comments"
rows=10 cols=55 wrap="VIRTUAL"></textarea><p></font>
<!-- Button(s): -->
<table width=100% border=0 cellpadding=0 cellspacing=0>
<tr><td align=left valign=bottom></td><td
align=left valign=top><input type=submit
value="Submit Form" align="middle">
<input type=reset><br><font size=1></td></tr></table>
</form>
</BODY>
</HTML>
<br><br><br><br>
<a href="/bradleyfloors/inforequest/edit.nhtml"><FONT face="helvetica,arial" SIZE="1~" COLOR="#000088">Owners Suite</Font></a><br>