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<?php
// Set base path to pull public assets from...
$baseURL = 'http://www.planplusonline.us/';
//Retrieve and URL variables
$ebff_105494 = $_GET['ebff_105494'];
$ebff_105495 = $_GET['ebff_105495'];
$ebff_105496 = $_GET['ebff_105496'];
$ebff_105497 = $_GET['ebff_105497'];
$ebff_105498 = $_GET['ebff_105498'];
$ebff_105499 = $_GET['ebff_105499'];
$ebff_105500 = $_GET['ebff_105500'];
$ebff_105501 = $_GET['ebff_105501'];
?>
<html><head>
<title></title>
</head><body>
<div style="text-align: center;"><img alt="" src="https://www.planplusonline.us/servlet/BbsFileServlet?fileid=4638121&filekey=UW8as4W3" style="width: 165px; height: 165px;" /></div></body></html>
<SCRIPT type="text/javascript" src="https://www.planplusonline.us/ozLovDatePicker2.js"></SCRIPT><SCRIPT type="text/javascript" src="https://www.planplusonline.us/jsmain.js"></SCRIPT><SCRIPT type="text/javascript" src="https://www.planplusonline.us/menu.js"></SCRIPT><link rel="stylesheet" type="text/css" href="https://www.planplusonline.us/forms/all.css"><link rel="stylesheet" type="text/css" href="https://www.planplusonline.us/all.css">
<form name=ebfb_na action="https://www.planplusonline.us/forms/fmsubmit.jsp" method=post enctype="multipart/form-data">
<table width=100% cellspacing=0 cellpadding=1 border=0>
<tr>
<td class=normalSmall align=right nowrap><span class=requiredAsterisk>*</span>Recorded Line: </td>
<td class=normalSmall align=left nowrap><input type=checkbox name="ebff_106050" value=Y ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap><span class=requiredAsterisk>*</span>First Name: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105494 id=ebff_105494 class=textInput size=24 value="<?php echo $ebff_105494; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap><span class=requiredAsterisk>*</span>Last Name: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105495 id=ebff_105495 class=textInput size=24 value="<?php echo $ebff_105495; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Phone: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105500 id=ebff_105500 class=textInput size=24 value="<?php echo $ebff_105500; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Average Utility bill amount (Number): </td>
<td class=normalSmall align=left nowrap><input type=text class="textInput" name="ebff_105549" value="" size=30 ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Current Utility Provider: </td>
<td class=normalSmall align=left nowrap><input type=text class="textInput" name="ebff_105550" id="ebff_105550" value="" size=30 style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Home Type: </td>
<td class=normalSmall align=left nowrap><div class=styled-select><select name="ebff_105552" id="ebff_105552" style='width:200px;' ><option value=""> <option value="Single Family Home" > Single Family Home<option value="Condo/Townhome" > Condo/Townhome<option value="Duplex" > Duplex</select></div></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Address: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105496 id=ebff_105496 class=textInput size=24 value="<?php echo $ebff_105496; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>City: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105497 id=ebff_105497 class=textInput size=24 value="<?php echo $ebff_105497; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>State: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105498 id=ebff_105498 class=textInput size=24 value="<?php echo $ebff_105498; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Zip Code: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105499 id=ebff_105499 class=textInput size=24 value="<?php echo $ebff_105499; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Roof Type: </td>
<td class=normalSmall align=left nowrap><div class=styled-select><select name="ebff_105553" id="ebff_105553" style='width:200px;' ><option value=""> <option value="Asphalt" > Asphalt<option value="Metal" > Metal<option value="Slate" > Slate<option value="Tile" > Tile<option value="Wood" > Wood<option value="Corrugated Metal (DQ)" > Corrugated Metal (DQ)</select></div></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Roof Condition: </td>
<td class=normalSmall align=left nowrap><input type=text class="textInput" name="ebff_105554" id="ebff_105554" value="" size=30 style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Shading Problems: </td>
<td class=normalSmall align=left nowrap><div class=styled-select><select name="ebff_105555" id="ebff_105555" style='width:200px;' ><option value=""> <option value="Yes" > Yes<option value="No" > No</select></div></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>How long have you lived in the home?: </td>
<td class=normalSmall align=left nowrap><input type=text class="textInput" name="ebff_105556" id="ebff_105556" value="" size=30 style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Spouse (Title) name: </td>
<td class=normalSmall align=left nowrap><input type=text class="textInput" name="ebff_105557" id="ebff_105557" value="" size=30 style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Is your credit Score above 650?: </td>
<td class=normalSmall align=left nowrap><div class=styled-select><select name="ebff_105558" id="ebff_105558" style='width:200px;' ><option value=""> <option value="Yes" > Yes<option value="No" > No<option value="Not Sure" > Not Sure</select></div></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>BK, Leins, Judgements?: </td>
<td class=normalSmall align=left nowrap><div class=styled-select><select name="ebff_105577" id="ebff_105577" style='width:200px;' ><option value=""> <option value="BK" > BK<option value="Judgements" > Judgements<option value="Leins" > Leins<option value="N/A" > N/A</select></div></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Computer Access: </td>
<td class=normalSmall align=left nowrap><div class=styled-select><select name="ebff_105559" id="ebff_105559" style='width:200px;' ><option value=""> <option value="Yes" > Yes<option value="No" > No</select></div></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Email: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105501 id=ebff_105501 class=textInput size=24 value="<?php echo $ebff_105501; ?>" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Comments: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105503 id=ebff_105503 class=textInput size=24 value="" style='width:200px;' ></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Solar Consultation Date: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_107028 id=ebff_107028 class=textInput size=24 value='' style='width:200px;' ><img onMouseUp="javascript:displayDatePicker('ebff_107028');" src="https://www.planplusonline.us/graphics/ozicon18cal.gif" align=absmiddle></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap>Solar Consultation Time: </td>
<td class=normalSmall align=left nowrap><div class="styled-selectSmallDate-contain"><select name="ebff_107029_HH" id="ebfb_na_ebff_107029_HH" class=styled-selectSmallDate onChange="cf_hour_min_onchange('ebfb_na', 'ebff_107029');"><option value="NA"><option value="01" > 1<option value="02" > 2<option value="03" > 3<option value="04" > 4<option value="05" > 5<option value="06" > 6<option value="07" > 7<option value="08" > 8<option value="09" > 9<option value="10" > 10<option value="11" > 11<option value="12" > 12</select><select name="ebff_107029_MM" id="ebfb_na_ebff_107029_MM" class=styled-selectSmallDate onChange="cf_hour_min_onchange('ebfb_na', 'ebff_107029');"><option value="NA"><option value="00" > 00<option value="01" > 01<option value="02" > 02<option value="03" > 03<option value="04" > 04<option value="05" > 05<option value="06" > 06<option value="07" > 07<option value="08" > 08<option value="09" > 09<option value="10" > 10<option value="11" > 11<option value="12" > 12<option value="13" > 13<option value="14" > 14<option value="15" > 15<option value="16" > 16<option value="17" > 17<option value="18" > 18<option value="19" > 19<option value="20" > 20<option value="21" > 21<option value="22" > 22<option value="23" > 23<option value="24" > 24<option value="25" > 25<option value="26" > 26<option value="27" > 27<option value="28" > 28<option value="29" > 29<option value="30" > 30<option value="31" > 31<option value="32" > 32<option value="33" > 33<option value="34" > 34<option value="35" > 35<option value="36" > 36<option value="37" > 37<option value="38" > 38<option value="39" > 39<option value="40" > 40<option value="41" > 41<option value="42" > 42<option value="43" > 43<option value="44" > 44<option value="45" > 45<option value="46" > 46<option value="47" > 47<option value="48" > 48<option value="49" > 49<option value="50" > 50<option value="51" > 51<option value="52" > 52<option value="53" > 53<option value="54" > 54<option value="55" > 55<option value="56" > 56<option value="57" > 57<option value="58" > 58<option value="59" > 59</select><select name="ebff_107029_AP" id="ebfb_na_ebff_107029_AP" class=styled-selectSmallDate select onChange="cf_hour_min_onchange('ebfb_na', 'ebff_107029');"><option value="NA"><option value="AM" > AM<option value="PM" > PM</select></div><input type=hidden name="ebff_107029" id="ebfb_na_ebff_107029" value=""></td>
</tr>
<tr>
<td class=normalSmall align=right nowrap><span class=requiredAsterisk>*</span>Partner Email address: </td>
<td class=normalSmall align=left nowrap><input type=text name=ebff_105505 id=ebff_105505 style="width:200px;" class=textInput size=24 value="" ></td>
</tr>
<input type=hidden name="ebff_106022" value="Solar">
<tr>
<td> </td><td class=normalSmall align=left nowrap>
<input type=button name=update class=normalButton value=Submit onClick="proceed_save()">
<input type=hidden name=fbid value=24530>
<input type=hidden name=fbky value=GJHtuEjr>
<script>
function proceed_save() {
if( document.ebfb_na.elements['ebff_106050'].value == '' )
{
alert('Recorded Line is a required field. Please fill in a non empty value.');
return;
}
if( document.ebfb_na.elements['ebff_105494'].value == '' )
{
alert('First Name is a required field. Please fill in a non empty value.');
return;
}
if( document.ebfb_na.elements['ebff_105495'].value == '' )
{
alert('Last Name is a required field. Please fill in a non empty value.');
return;
}
if( document.ebfb_na.elements['ebff_105505'].value == '' )
{
alert('Partner Email address is a required field. Please fill in a non empty value.');
return;
}
document.ebfb_na.submit();
}
</script>
</td>
</tr>
</table>
</form>
<html><head> <title></title></head><body> </body></html>