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# Mold - #Mold# Asthma - #Asthma# Bacteria - #Bacteria# Water - #Water# VOCs/Odors - #Inspection# 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, SourcingOther, sourcing, DateSubmitted, Mold, Asthma, Bacteria, Water, Inspection, 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(SourcingOther)#' , NULL '#TRIM(Sourcing)#' , '#DATEFORMAT(NOW())#', #Mold#, #Asthma#, #Bacteria#, #Water#, #Inspection#, #OtherCheckbox#, '#Comments#')

Name

Address

City

State

       Zip

Daytime Phone Number

Fax

Email

Problems to be Addressed

Mold

Asthma

Bacteria/Pathogens

Water Loss/Drying

VOCs/Odors

Other (list below)

Comments

How Did You Hear About Us?

     If Other, Describe: