document.write("<!-- Web Form Generator 2.0 --><center><form method=\"post\" action=\"http://clients.xmailpro.com/scripts/addlead.pl\" target=\"_new\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"649154\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"amarilloglass\"><input type=\"hidden\" name=\"redirect\" value=\"http://clients.xmailpro.com/thankyou-coi.htm?m=audio\" id=\"redirect_cf62044c3b0cd71a7b39ec060a6745d5\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"SchedAppt\"><input type=\"hidden\" name=\"meta_message\" value=\"1\"><input type=\"hidden\" name=\"meta_required\" value=\"name,custom Phone,from,custom Glass Type\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div align=\"center\"><h2><strong><font size=\"5\" color=\"#660000\" face=\"Times New Roman\">**Schedule an Appointment**</font></strong> </h2></div></center></td></tr><tr><td>* Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>* Phone (xxx-xxx-xxxx):</td><td><input type=\"text\" name=\"custom Phone\" value=\"\" size=\"20\"></td></tr><tr><td>* Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>* Year/Make/Model:</td><td><input type=\"text\" name=\"custom Year-Make-Model\" value=\"\" size=\"20\"></td></tr><tr><td>* Type Glass :</td><td><select name=\"custom Glass Type\"><option value=\"Select One\">Select One</option><option value=\"Windshield\">Windshield</option><option value=\"Driver Side Door-Front\">Driver Side Door-Front</option><option value=\"Driver Side Door-Rear\">Driver Side Door-Rear</option><option value=\"Pass Side Door-Front\">Pass Side Door-Front</option><option value=\"Pass Side Door-Rear\">Pass Side Door-Rear</option><option value=\"Rear Glass\">Rear Glass</option><option value=\"Vent Glass\">Vent Glass</option><option value=\"Sunroof\">Sunroof</option></select></td></tr>    <tr><td colspan=2><center><div align=\"center\"><strong><br>&nbsp;You will receive a confirmation message<br> after clicking \"Submit\"</strong></div><div align=\"center\"><strong>&nbsp;</strong></div><div align=\"center\"><strong>Check your email immediately to proceed.</strong></div></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Submit\"></td></tr></table></form></center>");

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