[*WebForm*]

<title>Millbrook Motel</title>
[* include file="header.htm" *]


<table width="90%"  border="0" align="center" cellpadding="0" cellspacing="0" id="content">
  <tr>
    <td>

[*WebFormInput*]
	<H4>How May We Help You?</H4>
	<p><strong>Please fill out our online form with your questions or comments.</strong></p>

	
	
	<form method="post">
		<input type="hidden" name="sub" value="1">

<TABLE width="100%" BORDER="0" cellpadding=5>
 <TR>
  <TD width="217"> Name *</TD>	
  <TD width="252"><INPUT TYPE="text" NAME="realname" VALUE="" SIZE=30 maxlength="30"></TD>
</TR>
<TR>
	<TD>Address *</TD> 	
	<TD><INPUT TYPE="text" NAME="address" VALUE="" SIZE=30 maxlength="30"></TD>
</TR>
<TR>
	<TD>City *</TD>  
	<TD><INPUT TYPE="text" NAME="city" VALUE="" SIZE=30 maxlength="30"></TD>
</TR>
<TR>
	<TD>U.S. State or 
	  Canadian Province*</TD>
	<TD>
<select name="state_province" id="state_province">
<option value="" selected>Please Choose One</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="WY">Alberta</option>
<option value="WY">British Columbia</option>
<option value="WY">Manitoba</option>
<option value="WY">New Bruns.</option>
<option value="WY">New Found. & Lab.</option>
<option value="WY">Northwest Terri.</option>
<option value="WY">Nova Scotia</option>
<option value="WY">Nunavut (NWT)</option>
<option value="WY">P.E.I.</option>
<option value="WY">Ontario</option>
<option value="WY">Quebec</option>
<option value="WY">Saskatchewan</option>
<option value="WY">Yukon</option>
		</select></td>
</TR>
<TR>
	<TD>Zip or Postal Code*</TD>	
	<TD><INPUT TYPE="text" NAME="zip" VALUE="" SIZE=10 maxlength="10"></TD>
	</TR>
		<TR>
		<TD>Country <br>
		  (
		  if other than the U.S. or Canada)</TD>
	    <TD> <INPUT TYPE="text" NAME="country" VALUE="" SIZE=30 maxlength="30"></TD>
</TR>
<TR>
	<TD>E-mail address  *</TD>	
	<TD> <INPUT TYPE="text" NAME="email" VALUE="" SIZE=30 maxlength="30"></TD>
</TR>
<TR>
	<TD>Phone</TD> 	
	<TD><INPUT TYPE="text" NAME="homephone" VALUE="" SIZE=30 maxlength="30"></TD>
</TR>
</TABLE>
<B>How did you hear about our web site?</B>
<TABLE BORDER=0 WIDTH=100% CELLPADDING=0 CELLSPACING=0>
<TR>
	<TD WIDTH=247 height="76" VALIGN=TOP>
	<INPUT TYPE="radio" NAME="howfound" VALUE="you found us by using a search engine">
	Search engine<BR>
	<INPUT TYPE="radio" NAME="howfound" VALUE="you heard about our website from a business associate">
	Heard from business associate<BR>
	<INPUT TYPE="radio" NAME="howfound" VALUE="you knew about our website because you are a current customer">
	I'm a current customer<BR>	</TD>
	<TD VALIGN=TOP WIDTH=218>
	<INPUT TYPE="radio" NAME="howfound" VALUE="you heard about our website through a friend or family member">
	Friend or family member<BR>
	<INPUT TYPE="radio" NAME="howfound" VALUE="you saw an advertisement or link on the Web">
	Web Advertisement/Link<BR>
	<INPUT TYPE="radio" NAME="howfound" VALUE="you saw our url in an advertisement">
	Saw in newspaper ad<BR>
	</TD>
</TR>
</TABLE>
<p><B>What are your approximate dates of stay?</B>
    <br>
  From: 
  <INPUT NAME="stay from" TYPE="text" id="stay from" VALUE="" size="20" maxlength="20">
  To:
  <INPUT NAME="stay to" TYPE="text" id="stay to" VALUE="" size="20" maxlength="20">
  </p>
<p><B>Would you like to be added to our mailing list?</b>
    <input type="radio" name="maillist" value="yes">
    Yes
    <input type="radio" name="maillist" value="no">
    No
    </p>
<p><B>Please enter questions or comments below:</B>
  <br>
  <textarea name="comments" cols="55" rows="6" wrap="VIRTUAL" id="comments"></textarea>
</p>
<P align="center">
  <INPUT NAME="mail form" TYPE="submit" id="mail form" VALUE="Mail Form to Millbrook Motel">
</FORM>
<p class="smallText">All fields wih (*) are required but <u>never</u> given out to others.</p>

[*/WebFormInput*]

[*WebFormSubmitted*]

[* RedirectTo "thank_you.htm" *]
  
[*/WebFormSubmitted*]

	</td>
  </tr>
</table>
[* include file="footer.htm" *]