Request from, #Form.Name1# #form.email#, was sent on #dateformat(now())# ----- Name - #Form.Name1# Address - #Form.Address# City - #Form.City# State - #Form.State# Zip - #Form.Zip# Phone - #Form.AreaCode#-#Form.Phone# Fax - #Form.FaxAreaCode#-#Form.FaxPhone# Termites - #Termites# BedBugs - #BedBugs# Rodents - #Rodents# Cockroaches - #Cockroaches# DustMites - #DustMites# Other Check - #OtherCheckbox# Services_Other_Comments - #ServicesOtherComments# Comments - #Form.comments# Source - #Form.sourcing# If Other - #Form.SourcingOther#

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INSERT INTO Clientdata ( Name1, Address, City, State, Zip, Email, AreaCode, Phone, FaxAreaCode, FaxPhone, ServicesOtherComments, sourcing, SourcingOther, DateSubmitted, Termites, BedBugs, Rodents, Cockroaches, DustMites, OtherCheckbox, Comments ) VALUES ( NULL'#TRIM(Name1)#', NULL'#TRIM(Address)#', NULL'#TRIM(City)#', '#State#', NULL'#Zip#', NULL'#TRIM(Email)#', NULL'#AreaCode#', NULL'#TRIM(Phone)#', NULL'#TRIM(FaxAreaCode)#', NULL'#TRIM(FaxPhone)#', NULL'#TRIM(ServicesOtherComments)#', NULL'#TRIM(Sourcing)#', NULL'#TRIM(SourcingOther)#', '#DATEFORMAT(NOW())#', #Termites#, #BedBugs#, #Rodents#, #Cockroaches#, #DustMites#, #OtherCheckbox#, '#Comments#')

Name

Address

City

State

       Zip

Daytime Phone Number

Fax

Email

Problems to be Addressed

Termites

Bed Bugs

Rodents

Cockroaches

Dust Mites

Other (list below)

Comments

How Did You Hear About Us?

     If Other, Describe: