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<title>Submit New Location</title>

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<div align="center">

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<form name="form1" method="post" action="visitor_add_complete.php" onSubmit="return validateform()">

  <table border="1" cellspacing="0" cellpadding="0" bordercolor="#000000" width="100%">

    <tr>

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      <table border="0" cellspacing="0" width="100%" cellpadding="3">
              <tr> 
                <th vAlign="top" colspan="3" bgcolor="#666666"> <font color="#FFFFFF">Please 
                  fill out this form to submit a new location to our directory</font></th>
              </tr>
              <tr> 
                <td vAlign="top" colSpan="3" bgcolor="#F3F3F3"> <p align="center"><font color="#FF0000" size="2">* 
                    denotes a required field</font></td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">Company Name:</font></td>
                <td vAlign="top" colSpan="2"> <input name="name" size="20" maxlength="50"> 
                  <font color="#FF0000">*</font></td>
              </tr>
              <tr> 
                <td vAlign="top" noWrap><font color="#000000" size="2">Street 
                  Address:</font></td>
                <td vAlign="top" colSpan="2"> <input name="address1" size="20" maxlength="70"> 
                  <font color="#FF0000">*</font><font size="2"><br>
                  </font> <input name="address2" size="20" maxlength="70"></td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">City:</font></td>
                <td vAlign="top" colSpan="2"> <input size="15" name="city" maxlength="70"> 
                  <font color="#FF0000">*</font></td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">State:</font></td>
                <td vAlign="top"> <select size="1" name="state">
                    <option value="" selected>Select State</option>
                    <option value="AK">AK -Alaska</option>
                    <option value="AL">AL -Alabama</option>
                    <option value="AR">AR -Arkansas</option>
                    <option value="AZ">AZ -Arizona</option>
                    <option value="CA">CA -California</option>
                    <option value="CO">CO -Colorado</option>
                    <option value="CT">CT -Connecticut</option>
                    <option value="DC">DC -District of Columbia</option>
                    <option value="DE">DE -Delaware</option>
                    <option value="FL">FL -Florida</option>
                    <option value="GA">GA -Georgia</option>
                    <option value="IA">IA -Iowa</option>
                    <option value="ID">ID -Idaho</option>
                    <option value="IL">IL -Illinois</option>
                    <option value="IN">IN -Indiana</option>
                    <option value="KS">KS -Kansas</option>
                    <option value="KY">KY -Kentucky</option>
                    <option value="LA">LA -Louisiana</option>
                    <option value="MA">MA -Massachusetts</option>
                    <option value="MD">MD -Maryland</option>
                    <option value="ME">ME -Maine</option>
                    <option value="MI">MI -Michigan</option>
                    <option value="MN">MN -Minnesota</option>
                    <option value="MO">MO -Missourii</option>
                    <option value="MS">MS -Mississippii</option>
                    <option value="MT">MT -Montana</option>
                    <option value="NC">NC -North Carolina</option>
                    <option value="ND">ND -North Dakota</option>
                    <option value="NE">NE -Nebraska</option>
                    <option value="NH">NH -New Hampshire</option>
                    <option value="NJ">NJ -New Jersey</option>
                    <option value="NM">NM -New Mexico</option>
                    <option value="NV">NV -Nevada</option>
                    <option value="NY">NY -New York</option>
                    <option value="OH">OH -Ohio</option>
                    <option value="OK">OK -Oklahoma</option>
                    <option value="OR">OR -Oregon</option>
                    <option value="PA">PA -Pennsylvania</option>
                    <option value="RI">RI -Rhode Island</option>
                    <option value="SC">SC -South Carolina</option>
                    <option value="SD">SD -South Dakota</option>
                    <option value="TN">TN -Tennessee</option>
                    <option value="TX">TX -Texas</option>
                    <option value="UT">UT -Utah</option>
                    <option value="VA">VA -Virginia</option>
                    <option value="VT">VT -Vermont</option>
                    <option value="WA">WA -Washington</option>
                    <option value="WI">WI -Wisconsin</option>
                    <option value="WV">WV -West Virginia</option>
                    <option value="WY">WY -Wyoming</option>
                    
               
              
                  </select> <font color="#FF0000">*</font></td>

              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">Zip/Postal:</font></td>
                <td vAlign="top" colSpan="2"> <input size="10" name="zip" maxlength="6"> 
                  <font color="#FF0000">* no spaces</font></td>
              </tr>
              <tr> 
                <td vAlign="top" colSpan="3"> <hr color="#000000" SIZE="1"> </td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">Telephone:</font></td>
                <td vAlign="top" colSpan="2"> <input name="telephone" size="20" maxlength="15"><font color="#FF0000">*</font></td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">Text Number:</font></td>
                <td vAlign="top" colSpan="2"> <input name="text_number" size="20" maxlength="15"><font color="#FF0000"></font></td>
              </tr>
              <tr> 
                <td vAlign="top"><font size="2">Fax:</font></td>
                <td vAlign="top" colSpan="2"> <input name="fax" size="20" maxlength="15"></td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">Email:</font></td>
                <td vAlign="top" colSpan="2"> <input name="email" size="20" maxlength="100"></td>
              </tr>
              <tr> 
                <td vAlign="top"><font color="#000000" size="2">Website:</font></td>
                <td vAlign="top" colSpan="2"><font size="2">https://</font> <input name="website" size="30" maxlength="100"></td>
              </tr>
              <tr> 
                <td vAlign="top" colspan="3"> <hr color="#000000" SIZE="1"> </td>
              </tr>
              <!-- DO NOT REMOVE THE FOLLOWING 3 LINES -->
              ## {textboxes} ## 
              <tr> 
                <td vAlign="top" colspan="3"> <hr color="#000000" SIZE="1"> </td>
              </tr>
              <tr> 
                <td vAlign="top">&nbsp;</td>
                
                <td vAlign="top" colSpan="2"> <input type="submit" value=" Add New Location... "></td>
                
              </tr>
            </table>

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  </form>

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