<html>
<head>
<title>Request An Inspection</title>
</head>
<body topmargin="10" marginheight="10">
<SCRIPT LANGUAGE = "Javascript">
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{
if (form.CFName.value=="")
{
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</Script>
<FORM ACTION="request_webinsert.asp" METHOD="POST">
<INPUT TYPE=HIDDEN NAME="recipient" VALUE="paul@yournwinspector.com">
<INPUT TYPE=HIDDEN NAME="subject" VALUE="NPI Inspection Request">
<TABLE BORDER="0" ALIGN="center" WIDTH="500" CELLPADDING="0" cellspacing="0">
<TR>
<TD><FONT FACE="Tahoma" COLOR="#000099" SIZE="-1"><B>Client Information</B></FONT></TD>
<TD ALIGN="RIGHT"><FONT FACE="Tahoma" COLOR="#000099" SIZE="1">Please provide as much information as possible.</FONT></TD>
</TR>
<TR>
<TD COLSPAN="2" BGCOLOR="#000099"><IMG SRC="images/white1.gif" BORDER=0 ALT="" HEIGHT="1"></TD>
</TR>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" WIDTH="1" HEIGHT="10" BORDER="0" ALT=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">First Name:*</FONT></TD>
<TD><INPUT NAME="CFName" SIZE="30" VALUE="" maxlength="150"></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Last Name:*</FONT></TD>
<TD><INPUT NAME="CLName" SIZE="30" VALUE="" maxlength="150"></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Address:</FONT></TD>
<TD><INPUT NAME="CAddress" SIZE="42" VALUE=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Address2:</FONT></TD>
<TD><INPUT NAME="CAddress2" SIZE="42" VALUE=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">City:</FONT></TD>
<TD><FONT COLOR="#000000"><INPUT NAME="CCity" SIZE="30" VALUE=""></FONT></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">State, Zip:</FONT></TD>
<TD><FONT COLOR="#000000">
<SELECT NAME="CState" CLASS="input">
<OPTION VALUE="">State</OPTION>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="XX">OTHER</option>
</SELECT>
&nbsp;<INPUT NAME="CZip" SIZE="10" maxlength="10" value="">
</FONT></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Home Phone:</FONT></TD>
<TD><INPUT NAME="CPhone" SIZE="20" value="" maxlength="15"></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Work Phone:</FONT></TD>
<TD><INPUT NAME="CWPhone" SIZE="20" value="" maxlength="15"></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Cell Phone:</FONT></TD>
<TD><INPUT NAME="CCell" SIZE="20" value="" maxlength="15"></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Fax:</FONT></TD>
<TD><INPUT NAME="CFax" SIZE="20" value="" maxlength="15"></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Email:</FONT></TD>
<TD><INPUT NAME="CEmail" SIZE="25" value="" maxlength="50"></TD>
</TR>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" WIDTH="1" HEIGHT="10" BORDER="0" ALT=""></TD>
</TR>
<TR>
<TD COLSPAN="2"><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#16379B"><B>Inspection Site Information</B></FONT></TD>
</TR>
<TR>
<TD COLSPAN="2" BGCOLOR="#16379B"><IMG SRC="images/white1.gif" WIDTH="1" HEIGHT="1" BORDER="0" ALT=""></TD>
</TR>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" WIDTH="1" HEIGHT="5" BORDER="0" ALT=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Address:</FONT></TD>
<TD><INPUT NAME="IAddress" SIZE="42" VALUE=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Address2:</FONT></TD>
<TD><INPUT NAME="IAddress2" SIZE="42" VALUE=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">City:</FONT></TD>
<TD><FONT COLOR="#000000"><INPUT NAME="ICity" SIZE="30" VALUE=""></FONT></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">State, Zip:</FONT></TD>
<TD><FONT COLOR="#000000">
<SELECT NAME="IState" CLASS="input">
<OPTION VALUE="">State</OPTION>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="XX">OTHER</option>
</SELECT>
&nbsp;<INPUT NAME="IZip" SIZE="10" maxlength="10" value="">
</FONT></TD>
</TR>
<TR>
<TD VALIGN="middle"><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Property Type:</FONT></TD>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">
<SELECT NAME="IPropertyType" CLASS="input">
<OPTION VALUE=""></OPTION>
<option value="Single">Single Family Home</option>
<option value="Multi">Duplex/Multi-Family Home</option>
</SELECT>
</FONT>
</TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Age of Home:</FONT></TD>
<TD><INPUT NAME="IAge" SIZE="15" maxlength="10" value=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Total Sq. Footage:</FONT></TD>
<TD><INPUT NAME="ITotalSQFT" SIZE="25" maxlength="50" value=""></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Heated Sq. Footage:</FONT></TD>
<TD><INPUT NAME="IHeatedSQFT" SIZE="25" maxlength="50" value=""></TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Foundation:</FONT></TD>
<TD>
<SELECT NAME="IFoundation">
<OPTION VALUE=""></OPTION>
<OPTION VALUE="Slab">Slab on Grade</OPTION>
<OPTION VALUE="Raised">Raised Floor Accessible</OPTION>
<OPTION VALUE="Basement">Basement</OPTION>
</SELECT></TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2"># of Bedrooms:</FONT></TD>
<TD>
<SELECT NAME="IBedrooms">
<OPTION VALUE=""></OPTION>
<OPTION VALUE="1">1 bedroom</OPTION>
<OPTION VALUE="2">2 bedrooms</OPTION>
<OPTION VALUE="3">3 bedrooms</OPTION>
<OPTION VALUE="4">4 bedrooms</OPTION>
<OPTION VALUE="5">5 bedrooms</OPTION>
<OPTION VALUE="6+">6 bedrooms or more</OPTION>
</SELECT></TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2"># of Bathrooms:</FONT></TD>
<TD>
<SELECT NAME="IBathrooms">
<OPTION VALUE=""></OPTION>
<OPTION VALUE="1">1 bathrooms</OPTION>
<OPTION VALUE="2">2 bathrooms</OPTION>
<OPTION VALUE="3">3 bathrooms</OPTION>
<OPTION VALUE="4">4 bathrooms</OPTION>
<OPTION VALUE="5">5 bathrooms</OPTION>
<OPTION VALUE="6+">6 bathrooms or more</OPTION>
</SELECT></TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Occupied:</FONT></TD>
<TD>
<SELECT NAME="IOccupied">
<OPTION VALUE=""></OPTION>
<OPTION VALUE="Y">Yes</OPTION>
<OPTION VALUE="N">No</OPTION>
</SELECT></TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Utilities:</FONT></TD>
<TD>
<SELECT NAME="IUtilities">
<OPTION VALUE=""></OPTION>
<OPTION VALUE="On">Turned On</OPTION>
<OPTION VALUE="Off">Turned Off</OPTION>
</SELECT></TD>
</TR>
<TR>
<TD><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000">Inspection Date: <font size="1">(Requested)</font></FONT></TD>
<TD><INPUT NAME="IDate" SIZE="25" value="" maxlength="50"></TD>
</TR>
<TR>
<TD><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Inspection Time: <font size="1">(Requested)</font></FONT></TD>
<TD><INPUT NAME="ITime" SIZE="25" value="" maxlength="50"></TD>
</TR>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" BORDER=0 ALT="" HEIGHT="15"></TD>
</TR>
<TR>
<TD COLSPAN="2"><FONT FACE="Arial, Verdana" SIZE="2" COLOR="#000000"><b>Please include any additional information regarding the inspection site:</b></FONT></TD>
</TR>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" BORDER=0 ALT="" HEIGHT="4"></TD>
</TR>
<TR>
<TD valign="top"><FONT COLOR="#000000" FACE="Arial, Verdana " SIZE="2">Notes/Comments:</FONT></TD>
<TD><TEXTAREA NAME="INotes" ROWS="6" COLS="38" WRAP="virtual" TABINDEX="3"></TEXTAREA></TD>
</TR>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" BORDER=0 ALT="" HEIGHT="15"></TD>
</TR>
<TR>
<TD COLSPAN="2" ALIGN="CENTER">
<INPUT TYPE="Button" VALUE="Submit" onClick="validate(this.form)">&nbsp;
<INPUT TYPE="Reset"></TD>
</TR>
</FORM>
<TR>
<TD COLSPAN="2"><IMG SRC="images/white1.gif" BORDER=0 ALT="" HEIGHT="25"></TD>
</TR>
</TABLE>
</body>
</html>





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