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Freedback Form -->
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<form enctype="multipart/form-data" method="post" action="http://www.freedback.com/mail.php"
accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="54w6r0hw011zfwde" />
<input type="hidden" name="formid" id="formid" value="740553" />
<input type="hidden" name="required_vars" id="required_vars"
value="name,field-1e60507657cb465,field-5154e39280d2010,field-e0650626f80ffa8,field-54cdb696275db2e,email,field-65bc5b651842617,field-066664673d72dcb,field-1dd1aaa937710dd,field-0ec30399d406915,field-edaeed1f61bb3c8,field-06804b10f145f44,field-8a114fb66a9ab3c,field-3c63719629e84d0"
/>
</div>
<table cellspacing="5" cellpadding="5" border="0">
<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">
<input type="text" name="field-1e60507657cb465" id="field-1e60507657cb465"
size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>City, State, Zip Code</strong>
</td>
<td valign="top">
<input type="text" name="field-5154e39280d2010" id="field-5154e39280d2010"
size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Best Phone Contact Number</strong>
</td>
<td valign="top">
<input type="text" name="field-e0650626f80ffa8" id="field-e0650626f80ffa8"
size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Emergency Contact</strong>
</td>
<td valign="top">
<input type="text" name="field-54cdb696275db2e" id="field-54cdb696275db2e"
size="40" value="" />
</td>
</tr>
<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>Are there children living in the home?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-65bc5b651842617[]"
id="field-65bc5b651842617_0" value="Yes" /> Yes<br/>
<input type="checkbox" name="field-65bc5b651842617[]"
id="field-65bc5b651842617_1" value="No" /> No<br/>
<input type="checkbox" name="field-65bc5b651842617[]"
id="field-65bc5b651842617_2" value="Not full time" /> Not full time<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Please list ages of your children.</strong>
</td>
<td valign="top">
<input type="text" name="field-d1c2f750c155bb4" id="field-d1c2f750c155bb4"
size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Have you ever owned a pet before?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-e0c17cc67a71318[]"
id="field-e0c17cc67a71318_0" value="Yes" /> Yes<br/>
<input type="checkbox" name="field-e0c17cc67a71318[]"
id="field-e0c17cc67a71318_1" value="No" /> No<br/>
<input type="checkbox" name="field-e0c17cc67a71318[]"
id="field-e0c17cc67a71318_2" value="As a child" /> As a child<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Do you currently own any pets?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-066664673d72dcb[]"
id="field-066664673d72dcb_0" value="Yes" /> Yes<br/>
<input type="checkbox" name="field-066664673d72dcb[]"
id="field-066664673d72dcb_1" value="No" /> No<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Please check current pets if any.</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_0" value="Cat(s)" /> Cat(s)<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_1" value="Kitten(s)" /> Kitten(s)<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_2" value="Dog(s)" /> Dog(s)<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_3" value="Puppy(s)" /> Puppy(s)<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_4" value="Other indoor critters" /> Other indoor
critters<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_5" value="Outdoor cat(s)" /> Outdoor cat(s)<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_6" value="Outdoor dog(s)" /> Outdoor dog(s)<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_7" value="Outdoor farm animals" /> Outdoor farm
animals<br/>
<input type="checkbox" name="field-94f1594ffbe481e[]"
id="field-94f1594ffbe481e_8" value="Exotics" /> Exotics<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Are your current pets spayed or neutered?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-208d368dc14496c[]"
id="field-208d368dc14496c_0" value="Yes" /> Yes<br/>
<input type="checkbox" name="field-208d368dc14496c[]"
id="field-208d368dc14496c_1" value="No" /> No<br/>
<input type="checkbox" name="field-208d368dc14496c[]"
id="field-208d368dc14496c_2" value="Not yet" /> Not yet<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Please list previous pets if any?</strong>
</td>
<td valign="top">
<textarea name="field-41b32847a3b2b44" id="field-41b32847a3b2b44" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Do you rent or own your home?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_0" value="Rent Apartment" /> Rent Apartment<br/>
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_1" value="Rent Townhouse" /> Rent Townhouse<br/>
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_2" value="Rent House" /> Rent House<br/>
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_3" value="Own Townhouse" /> Own Townhouse<br/>
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_4" value="Own House" /> Own House<br/>
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_5" value="Live with family member" /> Live with family
member<br/>
<input type="checkbox" name="field-1dd1aaa937710dd[]"
id="field-1dd1aaa937710dd_6" value="Other" /> Other<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>If you rent or live with a family member, please list the name and
telephone number of your landlord or apartment complex.</strong>
</td>
<td valign="top">
<textarea name="field-4199c29d2e5cf72" id="field-4199c29d2e5cf72" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>If you rent, does your rental agreement state any of the
following...</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-84a754965fd618e[]"
id="field-84a754965fd618e_0" value="Limited number of pets" /> Limited number of
pets<br/>
<input type="checkbox" name="field-84a754965fd618e[]"
id="field-84a754965fd618e_1" value="Weight limits" /> Weight limits<br/>
<input type="checkbox" name="field-84a754965fd618e[]"
id="field-84a754965fd618e_2" value="Breed specifics" /> Breed specifics<br/>
<input type="checkbox" name="field-84a754965fd618e[]"
id="field-84a754965fd618e_3" value="Pet deposits" /> Pet deposits<br/>
<input type="checkbox" name="field-84a754965fd618e[]"
id="field-84a754965fd618e_4" value="Pet fees" /> Pet fees<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Do you have a fenced yard?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-0ec30399d406915[]"
id="field-0ec30399d406915_0" value="Yes" /> Yes<br/>
<input type="checkbox" name="field-0ec30399d406915[]"
id="field-0ec30399d406915_1" value="No" /> No<br/>
<input type="checkbox" name="field-0ec30399d406915[]"
id="field-0ec30399d406915_2" value="Not yet" /> Not yet<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Please list what type of fencing you have.</strong>
</td>
<td valign="top">
<input type="text" name="field-d452eb690694c27" id="field-d452eb690694c27"
size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Please list the name and phone number of your current vet, one you
plan to use or one you have used in the past.</strong>
</td>
<td valign="top">
<textarea name="field-30bae0f568ae0d5" id="field-30bae0f568ae0d5" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Are you willing to use a crate and/or muzzle to help acclimate your
hound?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-edaeed1f61bb3c8[]"
id="field-edaeed1f61bb3c8_0" value="Yes" /> Yes<br/>
<input type="checkbox" name="field-edaeed1f61bb3c8[]"
id="field-edaeed1f61bb3c8_1" value="No" /> No<br/>
<input type="checkbox" name="field-edaeed1f61bb3c8[]"
id="field-edaeed1f61bb3c8_2" value="I need more information" /> I need more
information<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>How long will your hound be alone during your work day?</strong>
</td>
<td valign="top">
<textarea name="field-06804b10f145f44" id="field-06804b10f145f44" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Where do you intend to keep your hound while you are not
home?</strong>
</td>
<td valign="top">
<textarea name="field-8a114fb66a9ab3c" id="field-8a114fb66a9ab3c" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Where do you intend to keep your hound at night?</strong>
</td>
<td valign="top">
<textarea name="field-3c63719629e84d0" id="field-3c63719629e84d0" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Do you have any specific personality traits in mind that would
describe the type of pet you are looking for?</strong>
</td>
<td valign="top">
<textarea name="field-bfa217d6399aeab" id="field-bfa217d6399aeab" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Would you be interested in a special needs hound?</strong>
</td>
<td valign="top">
<input type="text" name="field-16a77f3da2e4f49" id="field-16a77f3da2e4f49"
size="40" value="" />
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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