Estimate

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=160 BGCOLOR="#FFFFFF" TEXT="#080000" background="0a9a0913.jpg"> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#CC3300" FACE="Arial" ><B>Two Ladies and a Mop</B></FONT><FONT SIZE="1" COLOR="#CC3300" FACE="Arial" > </FONT><FONT SIZE="1" COLOR="#FFCC33" FACE="Arial" > </FONT>   |     <A HREF="index.htm" TARGET="_top" TITLE="Two Ladies and a Mop"><U>home</U></A></div> <div> <A HREF="faq.htm" TARGET="_top" TITLE="F.A.Q."><U>F.A.Q.</U></A>   |   <A HREF="services.htm" TARGET="_top" TITLE="Our Services"><U>Our Services</U></A>   |   <A HREF="agreement.htm" TARGET="_top" TITLE="Service Agreement"><U>Service Agreement</U></A>   |   <A HREF="contact.htm" TARGET="_top" TITLE="Contact Us"><U>Contact Us</U></A>   |   <A HREF="coupons.htm" TARGET="_top" TITLE="Coupons"><U>Coupons</U></A>   |   <B>Estimate</B></div> <div> Estimate</div> <DIV ALIGN="LEFT"></DIV> <div> <B><IMG SRC="0674bc10.jpg" border=0 width="331" height="193" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div>    <form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8"> <div> <input type="hidden" name="acctid" id="acctid" value="hkb8mtsqx6hbzbmh" /> <input type="hidden" name="formid" id="formid" value="243045" /> <input type="hidden" name="required_vars" id="required_vars" value="name,field-0cc428a70d18844,field-de2f0de75b75f22" /> </div> <table cellspacing="5" cellpadding="5" border="0"> <tr> <td valign="top"> <strong>Email Address:</strong> </td> <td valign="top"> <input type="text" name="email" id="email" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Name:</strong> </td> <td valign="top"> <input type="text" name="name" id="name" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Address:</strong> </td> <td valign="top"> <textarea name="field-0cc428a70d18844" id="field-0cc428a70d18844" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>Best Ph. Number to Reach you:</strong> </td> <td valign="top"> <input type="text" name="field-de2f0de75b75f22" id="field-de2f0de75b75f22" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>What is the best time to reach you?</strong> </td> <td valign="top"> <input type="text" name="field-9819ecd922b4ab2" id="field-9819ecd922b4ab2" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>How did you hear about us?</strong> </td> <td valign="top"> <select name="field-197adebc44909c7" id="field-197adebc44909c7"> <option value="Decatur Daily">Decatur Daily</option> <option value="Coupon Express">Coupon Express</option> <option value="Hartselle Enquirer">Hartselle Enquirer</option> <option value="Athens Currier">Athens Currier</option> <option value="Online Search">Online Search</option> <option value="Word of Mouth">Word of Mouth</option> <option value="Other">Other</option> </select> </td> </tr> <tr> <td valign="top"> <strong>Comments:</strong> </td> <td valign="top"> <textarea name="field-e129cacd084e082" id="field-e129cacd084e082" rows="6" cols="40"></textarea> </td> </tr> <tr> <td colspan="2" align="center"> <input type="submit" value=" Submit Form " /> </td> </tr> </table> </form> <br><center><font face="Arial, Helvetica" size="1"><b> <a href="http://www.response-o-matic.com">form mail</a> </b></font></center>   </div> </td> </tr></table></body>