blackhat420

INPUT AREA HERE*************
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<form action="submit.php" method="post">
			<input name="Signing_from" value="Joes_page" type="checkbox"><table bgcolor="#98cd67" border="0" cellspacing="5">
				<tbody><tr><td>First Name</td><td><input size="30" name="first_name" type="text"></td></tr>
				<tr><td>Last Name</td><td><input size="30" name="last_name" type="text"></td></tr>
				<tr><td>Address</td><td><input size="30" name="Address" type="text"></td></tr>
				<tr><td>Phone Number</td><td><input size="30" name="Phone_Number" type="text"></td></tr>
				<tr><td><div align="right"><input type="checkbox" NAME="Signing_from" id="signing_form" VALUE="Email Statements" ></div><td><div align="left"> would like to enroll in e-mail statements</div></td></tr>
				<tr><td><div align="right"><input type="checkbox" NAME="Signing_from" id="rental_balance" VALUE="Rental Balance"></div><td><div align="left">Request rental balance copy</div></td></tr>

									<tr><td>Preferred Contact Time: </td>
									<td align="left"><select style="width: 140px;" name="preferred_contact_time">
										<option selected="selected" value="">Please select</option>
										<option value="morning">Morning</option>
										<option value="afternoon">Afternoon</option>
										<option value="evening">Evening</option></select>
								</td></tr><tr><td valign="top">Other information?</td><td><textarea name="Other_Information?" rows="6" cols="30"></textarea></td></tr>

								<tr><td>&nbsp;</td><td><input value="Send" type="submit"></td></tr>



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<ul><li><br><a href="http://urbanpharm.com/"><strong>Home</strong></a></li>
<li><a href="http://urbanpharm.com/property-management/"><strong>Property Management</strong></a></li>
<li><a href="http://urbanpharm.com/about/"><strong>About Us</strong></a></li>
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<h1>Welcome Urban Pharm tenants.</h1>
<p>Below, you&#8217;ll find some documents that are frequently requested.
Also, please use the form below to enroll in e-mail statements, request
rental balances, report maintenance issues, refer a friend or family
member, or contact us regarding any other issue.</p><br><br>
<div id="pdf">
<ul><li><a href="http://urbanpharm.com/current/pdf/Assistance%20List.pdf">Assistance List</a></li>
<li><a href="http://urbanpharm.com/current/pdf/Community%20Rules.pdf">Community Rules</a></li>
<li><a href="http://urbanpharm.com/current/pdf/Notice%20to%20Vacate%20or%20Renew.pdf">Notice to Vacate or Renew</a></li>
<li><a href="http://urbanpharm.com/current/pdf/Tenant%20contact%20&amp;%20comment%20form.pdf">Tenant Contant and Comment Form</a></li></ul>
</div><br><br><br><br><br><br><br>

<form action="submit.php" method="post">
			<input name="Signing_from" value="Joes_page" type="checkbox"><table bgcolor="#98cd67" border="0" cellspacing="5">
				<tbody><tr><td>First Name</td><td><input size="30" name="first_name" type="text"></td></tr>
				<tr><td>Last Name</td><td><input size="30" name="last_name" type="text"></td></tr>
				<tr><td>Address</td><td><input size="30" name="Address" type="text"></td></tr>
				<tr><td>Phone Number</td><td><input size="30" name="Phone_Number" type="text"></td></tr>
				<tr><td><div align="right"><input type="checkbox" NAME="Signing_from" id="signing_form" VALUE="Email Statements" ></div><td><div align="left"> would like to enroll in e-mail statements</div></td></tr>
				<tr><td><div align="right"><input type="checkbox" NAME="Signing_from" id="rental_balance" VALUE="Rental Balance"></div><td><div align="left">Request rental balance copy</div></td></tr>

									<tr><td>Preferred Contact Time: </td>
									<td align="left"><select style="width: 140px;" name="preferred_contact_time">
										<option selected="selected" value="">Please select</option>
										<option value="morning">Morning</option>
										<option value="afternoon">Afternoon</option>
										<option value="evening">Evening</option></select>
								</td></tr><tr><td valign="top">Other information?</td><td><textarea name="Other_Information?" rows="6" cols="30"></textarea></td></tr>

								<tr><td>&nbsp;</td><td><input value="Send" type="submit"></td></tr>

							<!--<table border="0" bgcolor="#a9d4c0" cellspacing="5">
								<tr><td>Reason for Loan</td><td><input type="text" size="30" name="reason_for_loan" /></td></tr>
								<tr><td>Value of Property</td><td><input type="text" size="30" name="email" /></td></tr>
								<tr><td>Type of Property</td><td><input type="text" size="30" name="email" /></td></tr>
								<tr><td>Loan Request Amount</td><td><input type="text" size="30" name="email" /></td></tr><br /><br /><br />
								
								<tr><td>&nbsp;</td><td><input type="submit" value="Send" /></td></tr>-->
							</tbody></table>
						</form><br><br><br>




<div id="addy">
<div class="organization"><strong>Urban Pharm, LLC</strong></div>
<div class="address"></div>
<div class="location">
		<span class="city">Grand Rapids</span>
		<abbr class="state" title="Iowa">MI</abbr>
		<span class="zip">49506</span>

</div>
<div class="phone">(616) 855-4540</div>
<div class="email"><a href="mailto:contact@urbanpharm.com?subject=Contact%20from%20UrbanPharm.com" title="contact@urbanpharm.com">contact@urbanpharm.com</a></div>
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<h2><span>Why Urban Pharm?</span></h2>
<p>We aim to satisfy all of our clients&#8212;which is a broad base. From
property owners and renters to buyers and sellers. Our tenants know
that we will take care of them and their home to the best of our
ability. Our borrowers have faith that we are looking out for their
best interests&#8212;not our pockets. Our buyers trust that we have improved
their new homes in a manner that makes...</p>
<p><a href="http://urbanpharm.com/why/">Learn more</a></p>

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