ÿþ<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3c.org/TR/1999/REC-html401-19991224/loose.dtd"> <HTML><HEAD> <META http-equiv=Content-Type content="text/html; charset=unicode"> <META content="MSHTML 6.00.6000.17023" name=GENERATOR></HEAD> <BODY> <DIV id=wrapper> <DIV align=center> <TABLE width=500 border=0> <TBODY> <TR> <TD align=middle> <DIV> <DIV> <P style="MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px" align=left><FONT style="COLOR: #000000">Simply complete our online service request form, and someone from our</FONT></P> <P style="MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px" align=left><FONT style="COLOR: #000000">friendly office staff will follow up to confirm your appointment.</FONT> </P> <P align=left>Please start here by letting us know how we may contact you to discuss your needs. All information you enter here is considered confidential, and will not be shared with any third parties. </P></DIV></DIV> <DIV><SPAN style="FONT-SIZE: 12px; COLOR: #ff0000">* Please note that all fields shown in red on this form are required.</SPAN> <DIV> <FORM action=formmail2.php method=post><INPUT type=hidden value=0 name=config> <DIV style="MARGIN-TOP: 10px; MARGIN-LEFT: 0%; MARGIN-RIGHT: 0%"> <FIELDSET style="PADDING-RIGHT: 5px; PADDING-LEFT: 10px"><LEGEND><STRONG>Contact Information</STRONG></LEGEND><BR> <TABLE cellSpacing=5 cellPadding=0 width=481 border=0> <TBODY> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>First Name <TD width=351> <P align=left><INPUT id=First-Name style="BACKGROUND-COLOR: #ffcc99" size=48 name=First-Name></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=bottom align=right width=98>Last Name <TD width=351> <P align=left><INPUT id=Last-Name style="BACKGROUND-COLOR: #ffcc99" size=48 name=Last-Name></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>Company <TD width=351> <P align=left><INPUT id=Company size=48 name=Company></P></TD> <TD width=12></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>Address <TD width=351> <P align=left><INPUT id=Address style="BACKGROUND-COLOR: #ffcc99" size=48 name=Address></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>City </TD> <TD width=351> <P align=left><INPUT style="BACKGROUND-COLOR: #ffcc99" size=48 name=City></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>State</TD> <TD width=351> <P align=left><INPUT style="BACKGROUND-COLOR: #ffcc99" size=25 name=State></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>Zip </TD> <TD width=351> <P align=left><INPUT style="BACKGROUND-COLOR: #ffcc99" size=10 name=Zip></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>Home Phone&nbsp;</TD> <TD width=351> <P align=left><INPUT size=31 name=Home-Phone></P></TD> <TD width=12></TD></TR> <TR vAlign=bottom> <TD vAlign=center align=right width=98>Office Phone&nbsp;</TD> <TD width=351> <P align=left><INPUT size=31 name=Office-Phone></P></TD> <TD width=12></TD></TR> <TR vAlign=bottom> <TD class=body-text-red vAlign=center align=right width=98>Email Address&nbsp;</TD> <TD width=351> <P align=left><INPUT id=Email style="BACKGROUND-COLOR: #ffcc99" size=49 name=Email></P></TD> <TD width=12><FONT color=#ff0000>*</FONT></TD></TR> <TR vAlign=center> <TD vAlign=center colSpan=3><BR><LABEL>Preferred Contact Method&nbsp;</LABEL> <SELECT id=contact-method name=Contact-Method> <OPTION value=Home_Phone selected>Home Phone</OPTION> <OPTION value=Office_Phone selected>Office Phone</OPTION> <OPTION value=Either_Phone selected>Either Phone</OPTION> <OPTION value=Email>Email</OPTION></SELECT> </TD></TR></TBODY></TABLE><BR></FIELDSET></DIV><BR> <DIV> <FIELDSET style="PADDING-LEFT: 10px"><LEGEND><STRONG>Services Requested</STRONG></LEGEND><BR> <table width="100%" border="0" cellpadding="0" cellspacing="0"> <TBODY> <span style='mso-fareast-font-family:"Times New Roman"'><o:p> <TR><B>Free Estimates:</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p></TD></TR> <TR><INPUT id=pest-control type=checkbox value=Free_pest_control_estimate name=Free_pest_control_estimate>&nbsp;Free Pest Control Estimate</TD></TR> <TR><INPUT id=termite-control type=checkbox value=Free_Termite_estimate name=Free_termite_estimate>&nbsp;Free Termite Control Estimate</TD></TR> <TR><INPUT id=mosquito-misting-system1 type=checkbox value=Free_Mosquito_Misting_System_Estimate name=mosquito_misting1>&nbsp;Free Mosquito Misting System Estimate </TD></TR> <TR><INPUT id=mold-control type=checkbox value=Free_mold_estimate name=Free_mold_estimate>&nbsp;Free Mold Control Estimate</TD></TR> <span style='mso-fareast-font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <TR><B>General Pest Control:</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p></TD></TR> <TR><INPUT id=ant-control0 type=checkbox value=ant-control name=ant-control0>&nbsp;Ant Control</TD></TR> <TR><INPUT id=bed-bug-control0 type=checkbox value=bed_bug_control name=bed-bug-control0>&nbsp;Bed Bug Control</TD></TR> <TR><INPUT id=cockroach-control type=checkbox value=cockroach_control name=cockroach-control>&nbsp;Cockroach Control </TD></TR> <TR><INPUT id=flea-control type=checkbox value=flea_control name=flea-control>&nbsp;Flea Control </TD></TR> <TR><INPUT id=nuisance-bird-control0 type=checkbox value=nuisance_bird_control name=nuisance-bird-control0>&nbsp;Nuisance Bird Control</TD></TR> <TR><INPUT id=rodent-control type=checkbox value=Rodent_Control name=Rodent_Control>&nbsp;Rodent Control</TD></TR> <TR><INPUT id=spider-control2 type=checkbox value=Spider_Control name=Spider_Control>&nbsp;Spider Control</TD></TR> <TR><INPUT id=other3 type=checkbox value=Other name=Other0>&nbsp;Other&nbsp; <INPUT id=service-for-other1 size=55 name=Service_Other0></TD></TR> <span style='mso-fareast-font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <TR><B>Termite Control Services:</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p></TD></TR> NOTE: All these options -- with the exception of "WDIR" -- are for those that have already received an estimate or are already under contract with us. See "Free Estimates" above" first if you haven't received a free estimate or are not under contract as yet. <o:p></o:p></span></p></TD></TR> <TR><INPUT id=termite-pretreatment type=checkbox value=termite_pretreatment name=termite-pretreatment>&nbsp;Preconstruction Termite Treatment</TD></TR> <TR><INPUT id=termite-booster-treatment type=checkbox value=termite_booster_treatment name=termite-booster-treatment>&nbsp;Termite Booster Treatment</TD></TR> <TR><INPUT id=termite-renewal type=checkbox value=termite_renewal name=termite-renewal>&nbsp;Termite Renewal</TD></TR> <TR><INPUT id=termite-spot-treatment type=checkbox value=termite_spot_treatment name=termite-spot-treatment>&nbsp;Termite Spot Treatment </TD></TR> <TR><INPUT id=termite-treatment-new0 type=checkbox value=termite_treatment_new name=termite-treatment-new0>&nbsp;Termite Treatment</TD></TR> <TR><INPUT id=WDIR0 type=checkbox value=WDIR name=WDIR0>&nbsp;WDIR (Termite Report for a Real Estate Transaction)</TD></TR> <span style='mso-fareast-font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></p> <TR><B>Account Type:</span></b><span style='mso-fareast-font-family:"Times New Roman"'><o:p></o:p></span></p></TD></TR> <TR><INPUT type=radio CHECKED value=commercial name=service-for>&nbsp;Commercial</TD></TR> <TR><INPUT type=radio CHECKED value=industrial name=service-for>&nbsp;Industrial</TD></TR> <TR><INPUT type=radio CHECKED value=Maritime name=service-for>&nbsp;Maritime</TD></TR> <TR><INPUT type=radio value=Residential name=service-for>&nbsp;Residential</TD></TR> </TABLE><BR /></FIELDSET></DIV><BR /> <DIV><FIELDSET style="PADDING-LEFT: 5px;" > <LEGEND><STRONG>Schedule an Appointment</STRONG></LEGEND> <TABLE cellSpacing=0 cellPadding=0 border=0> <TR> <TD><BR>Choose the best day to schedule an appointment. One of our customer service representatives will contact you with the confirming date and time. <BR></TD></TR> <TR> <TD> <TABLE cellSpacing=5 cellPadding=0 border=0> <TBODY> <TR> <TD><INPUT type=radio CHECKED value=Monday name=bestDay></TD> <TD>MON</TD> <TD><INPUT type=radio value=Tuesday name=bestDay></TD> <TD>TUE</TD> <TD><INPUT type=radio value=Wednesday name=bestDay></TD> <TD>WED</TD> <TD><INPUT type=radio value=Thursday name=bestDay></TD> <TD>THU</TD> <TD><INPUT type=radio value=Friday name=bestDay></TD> <TD>FRI</TD> <TD><INPUT type=radio value=Saturday name=bestDay></TD> <TD>SAT</TD> </TR></TBODY></TABLE></TD></TR> <TR> <TD><BR>Choose the best time of day to schedule an appointment.</TD></TR> <TR> <TD> <TABLE cellSpacing=5 cellPadding=0 border=0> <TBODY> <TR> <TD>&nbsp;&nbsp;&nbsp;<INPUT type=radio CHECKED value="Early Morning" name=bestTime></TD> <TD noWrap>Early Morning (6 am to 8 am)</TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<INPUT type=radio value=Morning1 name=bestTime></TD> <TD noWrap>Morning (8 am to 11 am)</TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<INPUT type=radio value=Midday1 name=bestTime></TD> <TD noWrap>Midday (11 am to 3 pm)</TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<INPUT type=radio value=Afternoon name=bestTime></TD> <TD noWrap>Afternoon (3 pm to 6 pm)</TD></TR></TBODY></TABLE></TD></TR></TBODY></TABLE><BR></FIELDSET></DIV> <P><FONT color=#cc0000>* = Required Field) </FONT>&nbsp;&nbsp;&nbsp; <INPUT type=submit value=Submit name=Submit><INPUT type=reset value=Reset name=Reset> </P></FORM></DIV></DIV> <P>&nbsp;</P></TD></TR></TBODY></TABLE></DIV></DIV></BODY></HTML>