document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub4.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=284354761&formid=4028&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:284354761:4:4028\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>Keep In Touch</div></div> <div class=\"bn-form-desc\"><p>Please fill out the fields and press submit.</p></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">First Name <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"your first name\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Last Name </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1704391423355106\" placeholder=\"your last name\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Country <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-170439136377332\" placeholder=\"your country\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Email Address <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-2\" placeholder=\"you must enter a valid email address\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row\"><span class=\"bn-label\">Rate This Site <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-select\"><select name=\"Field-170439092852150[]\" required=\"required\"><option value=\"Choose One\" selected=\"selected\">Choose One</option><option value=\"Pretty Good\">Pretty Good</option><option value=\"Mediocre\">Mediocre</option><option value=\"Pretty Bad\">Pretty Bad</option><option value=\"Needs Word\">Needs Word</option><option value=\"Very Excellent\">Very Excellent</option></select></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Comments <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"enter your comments here\" validator=\"\" required=\"required\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"debcarverowens@outlook.com\"> <input type=\"hidden\" name=\"thankyou\" value=\"http://debcarverowens.com/thanks.html\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"\"> <input type=\"hidden\" name=\"subject\" value=\"Someone filled out your form.\"><div class=\"bn-form-submit\"><button type=\"submit\" class=\"formbtn\">Submit Form</button></div> <style type=\"text/css\">.bnet-form ::-webkit-input-placeholder {');
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