header,		Barnhart Transportation
header,         Quote Request Form
select,         *Are You a Broker?,NO,YES
select,         *Priority Load,NO,YES
header
text,           *Contact Email,email
text,           *Contact Phone,number
text,           *Contact Name,cname
text,		*Company Name,from
text,		Reply Email(if different),email1
header,         Contact Address
text,           Street Address,address1
text,           Street Address 2,address2
text,           City,city
text,           State,State
text,           *Zip Code,zip
text,           *Your Country,country
header,         Please enter times in 24hr format
text,           *Pick Up Date,pdate
text,           *No Later Than,ptime
text,           *Delivery Date,ddate
text,           *Earliest Delivery,dtime
header
select,         *Hazmat?,Yes,No
select,         *Load Type,Legal Load,LTL,Power Only,Over Dimensional, Other
text,           *If "Other":,otherld
radio,          *Trailer Type,Flatbed,Step Deck,Conestoga Step Deck,RGN (23'4" Well),Other
text,           *If "Other":,othertlr
header,         Description of item to be moved
textarea,       *Load Description
header,         *Origin
text,           Street Address,oaddress1
text,           Street Address 2,oaddress2
text,           City,ocity
text,           State,oState
text,           *Zip Code,ozip
select,         *Country,United States,Canada,Mexico
header,         *Destination
text,           Street Address,daddress1
text,           Street Address 2,daddress2
text,           City,dcity
text,           State,dState
text,           *Zip Code,dzip
select,         *Country,United States,Canada,Mexico

textarea,	*Please enter any additional comments or questions.

header,		Email 
select,		Contact me By:,Phone,Email
radio,          Add me to your mailing list!,YES,NO
submit,		Send a Message!
header, Your quote request will be processed and we will contact you soon.