<!-- Begin Response-O-Matic Form -->
<!-- DO NOT EDIT YOUR FORM HERE, PLEASE LOG IN AND EDIT AT RESPONSE-O-MATIC.COM -->
<form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8">
 <div>
  <input type="hidden" name="acctid" id="acctid" value="o219lylwlewxlztu" />
  <input type="hidden" name="formid" id="formid" value="471771" />
  <input type="hidden" name="required_vars" id="required_vars" value="name,field-cbdd9f47a8143a7,field-a8f5dd9e48422d6,email,field-f7fc2863419d3d6" />
 </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>What city are you from?</strong>
   </td>
   <td valign="top">
    <input type="text" name="field-cbdd9f47a8143a7" id="field-cbdd9f47a8143a7" size="40" value="" />
    
   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>What state?</strong>
   </td>
   <td valign="top">
    <input type="text" name="field-a8f5dd9e48422d6" id="field-a8f5dd9e48422d6" 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>Whats your email about?</strong>
   </td>
   <td valign="top">
    <input type="radio" name="field-f7fc2863419d3d6" id="field-f7fc2863419d3d6_0" value="Haunting" /> Haunting<br/>
    <input type="radio" name="field-f7fc2863419d3d6" id="field-f7fc2863419d3d6_1" value="Unexplained" /> Unexplained<br/>
    <input type="radio" name="field-f7fc2863419d3d6" id="field-f7fc2863419d3d6_2" value="Other" /> Other<br/>
    
   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>Tell us whats on your mind</strong>
   </td>
   <td valign="top">
    <textarea name="field-9caa97fc691a69b" id="field-9caa97fc691a69b" rows="6" cols="40"></textarea>
    
   </td>
  </tr>
  <tr>
   <td colspan="2" align="center">
    <input type="submit" value=" Submit Form " />
   </td>
  </tr>
 </table>
</form>
<br><center><font face="Arial, Helvetica" size="1"><b>
<a href="http://www.response-o-matic.com">form mail</a>
</b></font></center>
<!-- End Response-O-Matic Form -->