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Path: /data/17/1/18/11/1670011/user/1801231/htdocs/tanningonline_com/ [ Home ]
File: finance-form.php
<?php
	$success 	= false;
	$error		= ''; 
	include('captcha/securimage.php');
	$captcha = new Securimage();
	$valid = $captcha->check($_POST['captcha_code']);
	
	$form['company_info'] = array(
		'ci_company_name' 		=> array('text' => 'Full Legal Company Name'),
		'ci_address' 			=> array('text' => 'Address'),
		'ci_city'				=> array('text' => 'City'),
		'ci_county'				=> array('text' => 'County'),
		'ci_state'				=> array('text' => 'State'),
		'ci_zip'				=> array('text' => 'Zip'),
		'ci_contact_person'		=> array('text' => 'Contact Person'),
		'ci_telephone'			=> array('text' => 'Telephone'),
		'ci_fax'				=> array('text' => 'Fax'),
		'ci_email'				=> array('text' => 'E-mail Address'),
		'ci_nature'				=> array('text' => 'Nature of Business'),
		'ci_corp_other'			=> array('text' => 'Corp/Other'),
		'ci_yrs_in_business'	=> array('text' => 'Yrs In Bus'),
		'ci_location'			=> array('text' => 'Location of Equipment (if different than above)'),
		'ci_amount'				=> array('text' => 'Amount'),
		'ci_term'				=> array('text' => 'Term'),
		'ci_payment'			=> array('text' => 'Payment'),
		'ci_adv_payments'		=> array('text' => 'Adv Payments'),
		'ci_buy_out'			=> array('text' => 'Buy-Out'),
		'ci_new_used'			=> array('text' => 'New/Used'),
		'ci_description'		=> array('text' => 'Equipment Description'),
		'ci_yrs_in_location'	=> array('text' => 'Yrs. at Loc'),
		'ci_estimated_delivery'	=> array('text' => 'Est. Equip Delivery Date')
	); 
	
	$form['personal_info'] = array(
		'pi_name1'				=> array('text' => 'Name'),
		'pi_title1'				=> array('text' => 'Title'),
		'pi_ss1'				=> array('text' => 'Social Security Number'),
		'pi_percent_ownership1'	=> array('text' => '% Ownership'),
		'pi_home_address1'		=> array('text' => 'Home Address'),
		'pi_city1'				=> array('text' => 'City'),
		'pi_state1'				=> array('text' => 'State'),
		'pi_telephone1'			=> array('text' => 'Home Telephone Number'),
		'pi_name2'				=> array('text' => 'Name'),
		'pi_title2'				=> array('text' => 'Title'),
		'pi_ss2'				=> array('text' => 'Social Security Number'),
		'pi_percent_ownership2'	=> array('text' => '% Ownership'),
		'pi_home_address2'		=> array('text' => 'Home Address'),
		'pi_city2'				=> array('text' => 'City'),
		'pi_state2'				=> array('text' => 'State'),
		'pi_telephone2'			=> array('text' => 'Home Telephone Number'),
		'pi_other_owner'		=> array('text' => 'List Other Owners'),
		'pi_title3'				=> array('text' => 'Title'),
		'pi_ss3'				=> array('text' => 'Social Security Number'),
		'pi_percent_ownership3'	=> array('text' => '% Ownership'),
	);
	$form['bank_info'] = array(
		'bi_current_name'				=> array('text' => 'Name of Bank'),
		'bi_current_years'				=> array('text' => 'Number Of Years'),
		'bi_current_acct'				=> array('text' => 'Bus Acct Number(s)'),
		'bi_current_phone'				=> array('text' => 'Telephone'),
		'bi_current_contact'			=> array('text' => 'Contact'),
		'bi_prev_name'					=> array('text' => 'Previous Bank'),
		'bi_prev_years'					=> array('text' => 'Number Of Years'),
		'bi_prev_acct'					=> array('text' => 'Bus Acct Number(s)'),
		'bi_prev_phone'					=> array('text' => 'Telephone'),
		'bi_prev_contact'				=> array('text' => 'Contact')
	);
	$form['trade_info'] = array(
		'ti_main_supplier'				=> array('text' => 'Main Supplier'),
		'ti_main_products'				=> array('text' => 'Products'),
		'ti_account_number'				=> array('text' => 'Account Number'),
		'ti_telephone'					=> array('text' => 'Telephone'),
		'ti_contact'					=> array('text' => 'Contact'),
		'ti_other_supplier'				=> array('text' => 'Other Supplier'),
		'ti_other_products'				=> array('text' => 'Products'),
		'ti_other_account_number'		=> array('text' => 'Account Number'),
		'ti_other_telephone'			=> array('text' => 'Telephone'),
		'ti_other_contact'				=> array('text' => 'Contact')
	);
	
	
	$form['landlord_info'] = array(
		'li_equip'						=> array('text' => 'Landlord for Equipment Location'),
		'li_years'						=> array('text' => 'No. of Yrs'),
		'li_city_state'					=> array('text' => 'City/State'),
		'li_telephone'					=> array('text' => 'Telephone'),
		'li_contact'					=> array('text' => 'Contact'),
		'li_business'					=> array('text' => 'Business Insurance Company'),
		'li_business_years'				=> array('text' => 'No. of Yrs'),
		'li_prop_dmg'					=> array('text' => 'Property Damage &amp; Liability?'),
		'li_business_telephone'			=> array('text' => 'Telephone'),
		'li_business_contact'			=> array('text' => 'Contact'),
	);
	//var_dump($form);
	
	// Shortcut to variables
	$company_info 	= $form['company_info'];
	$personal_info 	= $form['personal_info'];
	$bank_info 		= $form['bank_info'];
	$trade_info 	= $form['trade_info'];
	$landlord_info 	= $form['landlord_info'];
	
	if (isset($_POST['submit_form']))
	{
		if ($valid)
		{
			$html  ='<table>'; 
			$html .= '<tr><td colspan="2" bgcolor="#CCCCCC"><h3>Company Info</h3></td></tr>'."\n";
			foreach($company_info as $key => $value)
			{
				$html .=
						'<tr>'."\n".
							'<th align="right">'.$value['text'].': </th>'."\n".
							'<td>'.$_POST[$key].'</td>'."\n".
						'</tr>'."\n";
			}
			$html .= '<tr><td colspan="2" bgcolor="#CCCCCC"><h3>Personal Info:</h3></td></tr>'."\n";
			foreach($personal_info as $key => $value)
			{
				$html .=
						'<tr>'."\n". 
							'<th align="right">'.$value['text'].': </th>'."\n".
							'<td>'.$_POST[$key].'</td>'."\n".
						'</tr>'."\n";
			}
			
			$html .= '<tr><td colspan="2" bgcolor="#CCCCCC"><h3>Bank References:</h3></td></tr>'."\n";
			foreach($bank_info as $key => $value)
			{
				$html .=
						'<tr>'. "\n".
							'<th align="right">'.$value['text'].': </th>'."\n".
							'<td>'.$_POST[$key].'</td>'."\n".
						'</tr>'."\n";
			}
			
			$html .= '<tr><td colspan="2" bgcolor="#CCCCCC"><h3>Trade Refereences:</h3></td></tr>'."\n";
			foreach($trade_info as $key => $value)
			{
				$html .=
						'<tr>'. "\n".
							'<th align="right">'.$value['text'].': </th>'."\n".
							'<td>'.$_POST[$key].'</td>'."\n".
						'</tr>'."\n";
			}
	
			$html .= '<tr><td colspan="2" bgcolor="#CCCCCC"><h3>Landlord And Insurance Information:</h3></td></tr>'."\n";
			foreach($landlord_info as $key => $value)
			{
				$html .=
						'<tr>'."\n". 
							'<th align="right">'.$value['text'].': </th>'."\n".
							'<td>'.$_POST[$key].'</td>'."\n".
						'</tr>'."\n";
			}
			
			
			$html .= '</table>';
			$to 		= 'andy@tanningonline.com';
			$from 		= 'finance@tanningonline.com';
			$subject 	= 'Finance Forms'; 
			
			$headers  = 'MIME-Version: 1.0' . "\r\n";
			$headers .= 'Content-type: text/html; charset=iso-8859-1' . "\r\n";
			$headers .= 'From: '.$from."\r\n";
			
			
			if (mail($to, $subject, $html,$headers))
			$success = true;
		}
		else
		{
			$error = '<h2 style="color:red;">Image code is invalid</h2>';
		}
		
	}

?>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
	<head>
		<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
		<meta http-equiv="X-UA-Compatible" content="IE=EmulateIE7" />
		
		<title></title>
		<link href="/css/form.css" rel="stylesheet" type="text/css" />
	</head>
	<body>
		<div id="container">
			<div class="row clearfix address">
				<div class="left col" style="border-right:1px solid #ccc;">
					310 Shearer Blvd.<br />
					Cocoa, FL 32922<br />
				</div>
				<div class="left" style="padding-left:10px;">
					Ph: 800.667.9189<br />
					Fax: 321.636.3445<br />
				</div>
				<div class="right">
					<img src="/images/logo_lease_finance.jpg" />
				</div>
			</div>
			<?php if ($success):?>
				<p>Your form finance application has been submitted.</p>
				<p>Thank You.</p>
			<?php else:?>
				<?php echo $error;?>
				<form id="lease-apps" method="post" action="">
					<h3>Company Information</h3>
					<div class="clearfix">
						<div class="left" style="width:600px; border-right:1px solid #ccc;">
							<div class="row">
								<?php echo $company_info['ci_company_name']['text'];?><br />
								<input type="text" class="large" value="<?php echo $_POST['ci_company_name']?>" name="ci_company_name" />
							</div>
							<div class="row">
								<?php echo $company_info['ci_address']['text'];?><br />
								<input type="text" class="large" value="<?php echo $_POST['ci_address'];?>" name="ci_address" />
							</div>
							<div class="row clearfix">
								<div class="left col">
									<?php echo $company_info['ci_city']['text'];?><br />
									<input type="text" class="med" value="<?php echo $_POST['ci_city'];?>" name="ci_city" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_county']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_county'];?>" name="ci_county" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_state']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_state'];?>" name="ci_state" style="width:158px;" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_zip']['text'];?><br />
									<input type="text" class="small" value="<?php echo $_POST['ci_zip'];?>" name="ci_zip" />
								</div>
							</div>
							
							<div class="row clearfix">
								<div class="left col">
									<?php echo $company_info['ci_contact_person']['text'];?><br />
									<input type="text" class="med" value="<?php echo $_POST['ci_contact_person'];?>" name="ci_contact_person" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_telephone']['text'];?><br />
									<input type="text" class="med" value="<?php echo $_POST['ci_telephone'];?>" name="ci_telephone" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_fax']['text'];?><br />
									<input type="text" class="small-med" value="<?php echo $_POST['ci_fax'];?>" name="ci_fax" style="width:210px;" />
								</div>
							</div>
							<div class="row clearfix">
								<div class="left col">
									<?php echo $company_info['ci_email']['text'];?><br />
									<input type="text" class="med" value="<?php echo $_POST['ci_email'];?>" name="ci_email" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_nature']['text'];?><br />
									<input type="text" class="med" value="<?php echo $_POST['ci_nature'];?>" name="ci_nature" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_corp_other']['text'];?><br />
									<input type="text" class=tiny value="<?php echo $_POST['ci_corp_other'];?>" name="ci_corp_other" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_yrs_in_business']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_yrs_in_business'];?>" name="ci_yrs_in_business" style="width:98px;" />
								</div>
							</div>
							<div class="row clearfix">
								<?php echo $company_info['ci_location']['text'];?><br />
								<input type="text" class="large" value="<?php echo $_POST['ci_location'];?>" name="ci_location" />
							</div>
					
						</div><!--  .left -->
						<div class="right" style="width:327px;padding-right:0;">
							<div class="row">
								<h3 style="margin-top:20px;">Equipment Quote</h3>
							</div>
							<div class="row clearfix">
								<div class="left col">
									<?php echo $company_info['ci_amount']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_amount'];?>" name="ci_amount" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_term']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_term'];?>" name="ci_term" />
								</div>
								<div class="left">
									<?php echo $company_info['ci_payment']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_payment'];?>" name="ci_payment" />
								</div>
							</div>
							<div class="row clearfix">
								<div class="left col">
									<?php echo $company_info['ci_adv_payments']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_adv_payments'];?>" name="ci_adv_payments" />
								</div>
								<div class="left col">
									<?php echo $company_info['ci_buy_out']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_buy_out'];?>" name="ci_buy_out" />
								</div>
								<div class="left">
									<?php echo $company_info['ci_new_used']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_new_used'];?>" name="ci_new_used" />
								</div>
							</div>
							<div class="row clearfix">
								<?php echo $company_info['ci_description']['text'];?><br />
								<textarea type="text" class="med" name="ci_description" /><?php echo $_POST['ci_description'];?></textarea>
							</div>	
							<div class="row clearfix">
								<div class="left col">
									<?php echo $company_info['ci_yrs_in_location']['text'];?><br />
									<input type="text" class="tiny" value="<?php echo $_POST['ci_yrs_in_location'];?>" name="ci_yrs_in_location" />
								</div>
								<div class="left">
									<?php echo $company_info['ci_estimated_delivery']['text'];?><br />
									<input type="text" class="med" value="<?php echo $_POST['ci_estimated_delivery'];?>" name="ci_estimated_delivery"  style="width:203px;"/>
								</div>
							</div>
						</div><!--  .right -->
					</div>
					
					<h3>Personal information For All Owners Officers And Guarantors</h3>
					
					<div class="row clearfix"> 
						<div class="left col">
							<?php echo $personal_info['pi_name1']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_name1'];?>" name="pi_name1" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_title1']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_title1'];?>" name="pi_title1" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_ss1']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_ss1'];?>" name="pi_ss1" />
						</div>
						<div class="left">
							<?php echo $personal_info['pi_percent_ownership1']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['pi_percent_ownership1'];?>" name="pi_percent_ownership1" />
						</div>
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $personal_info['pi_home_address1']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_home_address1'];?>" name="pi_home_address1" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_city1']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_city1'];?>" name="pi_city1" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_state1']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_state1'];?>" name="pi_state1" />
						</div>
						<div class="left">
							<?php echo $personal_info['pi_telephone1']['text'];?><br />
							<input type="text" class="tiny" value="<?php echo $_POST['pi_telephone1'];?>" name="pi_telephone1" style="width:240px;" />
						</div>
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $personal_info['pi_name2']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_name2'];?>" name="pi_name2" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_title2']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_title2'];?>" name="pi_title2" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_ss2']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_ss2'];?>" name="pi_ss2" />
						</div>
						<div class="left">
							<?php echo $personal_info['pi_percent_ownership2']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['pi_percent_ownership2'];?>" name="pi_percent_ownership2" />
						</div>
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $personal_info['pi_home_address2']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_home_address2'];?>" name="pi_home_address2" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_city2']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_city2'];?>" name="pi_city2" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_state2']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_state2'];?>" name="pi_state2" />
						</div>
						<div class="left">
							<?php echo $personal_info['pi_telephone2']['text'];?><br />
							<input type="text" class="tiny" value="<?php echo $_POST['pi_telephone2'];?>" name="pi_telephone2" style="width:240px;" />
						</div>
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $personal_info['pi_other_owner']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_other_owner'];?>" name="pi_other_owner" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_title3']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['pi_title3'];?>" name="pi_title3" />
						</div>
						<div class="left col">
							<?php echo $personal_info['pi_ss3']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['pi_ss3'];?>" name="pi_ss3" />
						</div>
						<div class="left">
							<?php echo $personal_info['pi_percent_ownership3']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['pi_percent_ownership3'];?>" name="pi_percent_ownership3" />
						</div>
					</div>
		
					
					<h3>Bank References</h3>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $bank_info['bi_current_name']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['bi_current_name'];?>" name="bi_current_name" />
						</div>
						<div class="left col">
							<?php echo $bank_info['bi_current_years']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['bi_current_years'];?>" name="bi_current_years" />
						</div>
						<div class="left col">
							<?php echo $bank_info['bi_current_acct']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST[''];?>" name="bi_current_acct" />
						</div>
						
						<div class="left col">
							<?php echo $bank_info['bi_current_phone']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST[''];?>" name="bi_current_phone" />
						</div>
						<div class="left">
							<?php echo $bank_info['bi_current_contact']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST[''];?>" name="bi_current_contact" style="width:178px;" />
						</div>
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $bank_info['bi_prev_name']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST[''];?>" name="bi_prev_name" />
						</div>
						<div class="left col">
							<?php echo $bank_info['bi_prev_years']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST[''];?>" name="bi_prev_years" />
						</div>
						<div class="left col">
							<?php echo $bank_info['bi_prev_acct']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST[''];?>" name="bi_prev_phone" />
						</div>
						<div class="left col">
							<?php echo $bank_info['bi_prev_phone']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST[''];?>" name="bi_prev_acct" />
						</div>
						<div class="left">
							<?php echo $bank_info['bi_prev_contact']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST[''];?>" name="bi_prev_contact" style="width:178px;"  />
						</div>
					</div>
		
			
			
					
					<h3>Trade References</h3>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $trade_info['ti_main_supplier']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['ti_main_supplier'];?>" name="ti_main_supplier" />
						</div>
						<div class="left col">
							<?php echo $trade_info['ti_main_products']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['ti_main_products'];?>" name="ti_main_products" />
						</div>
						<div class="left col">
							<?php echo $trade_info['ti_account_number']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['ti_account_number'];?>" name="ti_account_number" />
						</div>
						<div class="left col">
							<?php echo $trade_info['ti_telephone']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['ti_telephone'];?>" name="ti_telephone" />
						</div>
						<div class="left">
							<?php echo $trade_info['ti_contact']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['ti_contact'];?>" name="ti_contact" style="width:120px;" />
						</div>
							
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $trade_info['ti_other_supplier']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['ti_other_supplier'];?>" name="ti_other_supplier" />
						</div>
						<div class="left col">
							<?php echo $trade_info['ti_other_products']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['ti_other_products'];?>" name="ti_other_products" />
						</div>
						<div class="left col">
							<?php echo $trade_info['ti_other_account_number']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['ti_other_account_number'];?>" name="ti_other_account_number" />
						</div>
						<div class="left col">
							<?php echo $trade_info['ti_other_telephone']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['ti_other_telephone'];?>" name="ti_other_telephone" />
						</div>
						<div class="left">
							<?php echo $trade_info['ti_other_contact']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['ti_other_contact'];?>" name="ti_other_contact" style="width:120px;" />
						</div>
					</div>
	
						
					<h3>Landlord And Insurance Information</h3>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $landlord_info['li_equip']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['li_equip'];?>" name="li_equip" />
						</div>
						<div class="left col">
							<?php echo $landlord_info['li_years']['text'];?><br />
							<input type="text" class="tiny" value="<?php echo $_POST['li_years'];?>" name="li_years" />
						</div>
						<div class="left col">
							<?php echo $landlord_info['li_city_state']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['li_city_state'];?>" name="li_city_state" style="width:250px;" />
						</div>
						<div class="left col">
							<?php echo $landlord_info['li_telephone']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['li_telephone'];?>" name="li_telephone" />
						</div>
						<div class="left">
							<?php echo $landlord_info['li_contact']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['li_contact'];?>" name="li_contact" />
					</div>
					<div class="row clearfix">
						<div class="left col">
							<?php echo $landlord_info['li_business']['text'];?><br />
							<input type="text" class="med-large" value="<?php echo $_POST['li_business'];?>" name="li_business" />
						</div>
						<div class="left col">
							<?php echo $landlord_info['li_business_years']['text'];?><br />
							<input type="text" class="tiny" value="<?php echo $_POST['li_business_years'];?>" name="li_business_years" />
						</div>
						<div class="left col">
							<?php echo $landlord_info['li_prop_dmg']['text'];?><br />
							<input type="text" class="med" value="<?php echo $_POST['li_prop_dmg'];?>" name="li_prop_dmg" style="width:250px;" />
						</div>
						<div class="left col">
							<?php echo $landlord_info['li_business_telephone']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['li_business_telephone'];?>" name="li_business_telephone" />
						</div>
						<div class="left">
							<?php echo $landlord_info['li_business_contact']['text'];?><br />
							<input type="text" class="small" value="<?php echo $_POST['li_business_contact'];?>" name="li_business_contact" />
						</div>
					</div>
					<div class="row">
						<div class="col">
							Captcha Code <br />
							<input type="text" name="captcha_code" class="med-large" /> <br />
							<img id="captcha" src="/captcha/securimage_show.php" alt="CAPTCHA Image" /><br />
								<a href="#" onclick="document.getElementById('captcha').src = '/secureimage/securimage_show.php?' + Math.random(); return false">
									[ Reload Image ]
								</a>
						</div>
					</div>
					<div class="row">
						<div class="col">
							<input type="submit" value="send information" name="submit_form" />
						</div>
					</div>
				</form>
				<p class="authorized">
					Credit Authorization: I/We hereby authorize AQM, Inc., its designee, assigns or potential assigns to review his/her personal credit profile provided by
					national credit bureaus in considering this application and for the purpose of updating, renewing, extending additional credit or the collection of any late
					account. I/We hereby authorize our references to release all credit information and I/We represent and warrant that the information submitted herein is true,
					complete and accurate. A facsimile, electronic or other copy of this authorization shall be as valid as the original.
				</p>
			<?php endif;?>
		</div>
	</body>
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