<form action="sell_process.php" method="post">
                <table width="100%" cellpadding="2" cellspacing="2">
                  <tr>
                    <td colspan="2"><span class="style2">* Required Information</span></td>
                  </tr>
                  <tr>
                    <td width="43%"><strong>*Your Name:</strong></td>
                    <td width="57%"><label>
                      <input name="name" type="text" id="name" size="35">
                    </label></td>
                  </tr>
                  <tr>
                    <td><strong>*Property Address: </strong></td>
                    <td><input name="property_address" type="text" id="property_address" size="35"></td>
                  </tr>
                  <tr>
                    <td><strong>*Property  City:</strong></td>
                    <td><input name="property_city" type="text" id="property_city" size="35"></td>
                  </tr>
                  <tr>
                    <td><strong>*Property State:</strong></td>
                    <td><input name="property_state" type="text" id="property_state" size="35"></td>
                  </tr>
                  <tr>
                    <td><strong>*Zip:</strong></td>
                    <td><input name="property_zip" type="text" id="property_zip" size="35"></td>
                  </tr>
                  <tr>
                    <td><strong>*Phone: </strong></td>
                    <td><input name="phone" type="text" id="phone" size="35"></td>
                  </tr>
                  <tr>
                    <td><strong>*E-mail Address:</strong></td>
                    <td><input name="email" type="text" id="email" size="35"></td>
                  </tr>
                  <tr>
                    <td>Listed with Realtor?:</td>
                    <td><label>
                      <select name="listed" id="listed">
                        <option value="Yes">Yes</option>
                        <option value="No">No</option>
                      </select>
                    </label></td>
                  </tr>
                  <tr>
                    <td valign="top">Why are you
                      selling?</td>
                    <td><label>
                      <textarea name="why_sell" cols="35" rows="5" id="why_sell"></textarea>
                    </label></td>
                  </tr>
                  <tr>
                    <td>Property is:</td>
                    <td><label>
                      <select name="property_is" id="select2">
                        <option value="Owner Occupied">Owner Occupied</option>
                        <option value="Renter Occupied">Renter Occupied</option>
                        <option value="Vacant">Vacant</option>
                      </select>
                    </label></td>
                  </tr>
                  <tr>
                    <td>Property type:</td>
                    <td><select name="property_type" size="1" id="select3">
                        <option value="Single Family">Single Family</option>
                        <option value="Town House">Town House</option>
                        <option value="Duplex">Duplex</option>
                        <option value="Triplex ">Triplex </option>
                        <option value="Fourplex">Fourplex</option>
                        <option value="Apartments">Apartments</option>
                        <option value="Farm House">Farm House</option>
                        <option value="Commercial">Commercial</option>
                        <option value="Other ">Other </option>
                    </select></td>
                  </tr>
                  <tr>
                    <td>Age of house:</td>
                    <td><input name="house_age" type="text" id="house_age" size="20"></td>
                  </tr>
                  <tr>
                    <td>Square footage:</td>
                    <td><input name="square_footage" type="text" id="square_footage" size="20"></td>
                  </tr>
                  <tr>
                    <td>Garage:</td>
                    <td><select name="garage" size="1" id="select4">
                        <option value="One Car Attached">One Car Attached</option>
                        <option value="Two Car Attached">Two Car Attached</option>
                        <option value="Three Car Attached">Three Car Attached</option>
                        <option value="One Car Detached">One Car Detached</option>
                        <option value="Two Car Detached">Two Car Detached</option>
                        <option value="Three Car Detached">Three Car Detached</option>
                        <option value="Carport">Carport</option>
                        <option value="None">None</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td># of Bedrooms:</td>
                    <td><select name="bedrooms" size="1" id="select5">
                        <option value="1">1</option>
                        <option value="2">2</option>
                        <option value="3">3</option>
                        <option value="4">4</option>
                        <option value="5+">5+</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td># of Baths:</td>
                    <td><select name="bathrooms" size="1" id="select6">
                        <option value="1">1</option>
                        <option value="1.5">1.5</option>
                        <option value="2">2</option>
                        <option value="2.5">2.5</option>
                        <option value="3">3</option>
                        <option value="3.5">3.5</option>
                        <option value="4+">4+</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td>Overall condition 
                      of the house:</td>
                    <td valign="top"><select name="condition" size="1" id="select7">
                        <option value="Excellent">Excellent</option>
                        <option value="Good">Good</option>
                        <option value="Fair">Fair</option>
                        <option value="Poor">Poor</option>
                        <option value="UGLY!">UGLY!</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td valign="top">What repairs
                      are needed?</td>
                    <td><textarea name="repairs" cols="35" rows="5" id="textarea2"></textarea></td>
                  </tr>
                  <tr>
                    <td valign="top">Any upgrades or
                      remodeling
                      needed?</td>
                    <td><textarea name="upgrades" cols="35" rows="5" id="textarea3"></textarea></td>
                  </tr>
                  <tr>
                    <td>Age/Condition of Roof: </td>
                    <td><input name="roof_age" type="text" id="roof_age" size="35"></td>
                  </tr>
                  <tr>
                    <td colspan="2">&nbsp;</td>
                  </tr>
                  <tr>
                    <td><strong>Mortgage Information: </strong></td>
                    <td>&nbsp;</td>
                  </tr>
                  <tr>
                    <td>1st mortgage balance:</td>
                    <td><input name="mortgage_bal_1" type="text" id="mortgage_bal_1" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>1st mortgage payment amount:</td>
                    <td valign="top"><input name="mortgage_pay_1" type="text" id="mortgage_pay_1" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>2nd mortgage balance:</td>
                    <td><input name="mortgage_bal_2" type="text" id="mortgage_bal_2" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>2nd mortgage payment amount:</td>
                    <td valign="top"><input name="mortgage_pay_2" type="text" id="mortgage_pay_2" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>What is the balance of all
                      mortgages combined?</td>
                    <td valign="top"><input name="bal_combined" type="text" id="bal_combined" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>What is the combined monthly
                      payment on all mortgages?</td>
                    <td valign="top"><input name="payment_combined" type="text" id="payment_combined" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>Are all mortgage payments current:</td>
                    <td valign="top"><select name="mort_pay_current" size="1" id="select8">
                        <option>YES</option>
                        <option>NO</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td>If payments are not current
                      how far behind are they?</td>
                    <td valign="top"><input name="payments_behind" type="text" id="payments_behind" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>1st Mortgage $ Amount behind:</td>
                    <td valign="top"><input name="mortgage_behind_1" type="text" id="mortgage_behind_1" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>1st  Mortgage # of payments late:</td>
                    <td valign="top"><input name="mortgage_late_1" type="text" id="mortgage_late_1" size="35"></td>
                  </tr>
                  <tr>
                    <td>2nd Mortgage $ Amount behind:</td>
                    <td valign="top"><input name="mortgage_behind_2" type="text" id="mortgage_behind_2" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>2nd Mortgage # of payments late:</td>
                    <td valign="top"><input name="mortgage_late_2" type="text" id="mortgage_late_2" size="35"></td>
                  </tr>
                  <tr>
                    <td>Any Liens and or Title problems?</td>
                    <td valign="top"><select name="lien_title_problem" size="1" id="select9">
                        <option>YES</option>
                        <option>NO</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td valign="top">If yes, please explain:</td>
                    <td><textarea name="explain_lien_title" cols="35" rows="5" id="textarea4"></textarea></td>
                  </tr>
                  <tr>
                    <td>Have you been sent a
                      foreclosure notice?</td>
                    <td valign="top"><select name="foreclosure_notice" size="1" id="select10">
                        <option>YES</option>
                        <option>NO</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td>If yes, has the foreclosure sale
                      date been set? </td>
                    <td valign="top"><select name="foreclosure_sale_date" size="1" id="select11">
                        <option>YES</option>
                        <option>NO</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td>If so, when?</td>
                    <td><input name="foreclosure_sale_when" id="foreclosure_sale_when" value="mm/dd/yy" size="15"></td>
                  </tr>
                  <tr>
                    <td>How much are you
                      asking for your  house?</td>
                    <td valign="top"><input name="asking_for_house" type="text" id="asking_for_house" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>If we were to have the house
                      appraised, what do you think it
                      would appraise for?</td>
                    <td valign="top"><input name="house_appraise" type="text" id="house_appraise" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>How soon do you need to sell?</td>
                    <td valign="top"><input name="how_soon_to_sell" type="text" id="how_soon_to_sell" size="35"></td>
                  </tr>
                  <tr>
                    <td>If we could pay all cash and close
                      quickly, what is the least amount
                      you could accept?</td>
                    <td valign="top"><input name="least_to_accept" type="text" id="least_to_accept" value="$" size="35"></td>
                  </tr>
                  <tr>
                    <td>How did you hear about us?</td>
                    <td valign="top"><select name="hear_about_us" size="1" id="select12">
                        <option>Referral from Attorney</option>
                        <option>Referral from CPA</option>
                        <option>Referral from Friend</option>
                        <option>Referral from Realtor</option>
                        <option>Local Newspaper</option>
                        <option>Postcard Letter</option>
                        <option>Internet Search Engine</option>
                        <option>Link From other Internet Site</option>
                        <option>Other</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td valign="top">Additional Comments: </td>
                    <td><textarea name="comments" cols="35" rows="5" id="textarea5"></textarea></td>
                  </tr>
                  <tr>
                    <td>&nbsp;</td>
                    <td><label>
                      <input type="submit" name="Submit" value="Submit">
                    </label></td>
                  </tr>
                </table>
              </form>

 
 <?php
			  $to = "email@gmail.com";
			  $subject = "Jig Buys Home Property Information Form";
			  $headers = "From: propertyinfo@jigbuyshomes.com\r\n";
 
			  $name = $_REQUEST["name"];
			  $property_address = $_REQUEST["property_address"];
			  $property_city = $_REQUEST["property_city"];
			  $property_state = $_REQUEST["property_state"];
			  $property_zip = $_REQUEST["property_zip"];
			  $phone = $_REQUEST["phone"];
			  $email = $_REQUEST["email"];
     		  $listed = $_REQUEST["listed"];
			  $why_sell = $_REQUEST["why_sell"];
			  $property_is = $_REQUEST["property_is"];
			  $property_type = $_REQUEST["property_type"];
			  $house_age = $_REQUEST["house_age"];
			  $square_footage = $_REQUEST["square_footage"];
			  $garage = $_REQUEST["garage"];
			  $bedrooms = $_REQUEST["bedrooms"];
			  $bathrooms = $_REQUEST["bathrooms"];
			  $condition = $_REQUEST["condition"];
			  $repairs = $_REQUEST["repairs"];
			  $upgrades = $_REQUEST["upgrades"];
			  $roof_age = $_REQUEST["roof_age"];
			  $mortgage_bal_1 = $_REQUEST["mortgage_bal_1"];
			  $mortgage_pay_1 = $_REQUEST["mortgage_pay_1"];
			  $mortgage_bal_2 = $_REQUEST["mortgage_bal_2"];
			  $mortgage_pay_2 = $_REQUEST["mortgage_pay_2"];
			  $bal_combined = $_REQUEST["bal_combined"];
			  $payment_combined = $_REQUEST["payment_combined"];
			  $mort_pay_current = $_REQUEST["mort_pay_current"];
			  $payments_behind = $_REQUEST["payments_behind"];
			  $mortgage_behind_1 = $_REQUEST["mortgage_behind_1"];
			  $mortgage_late_1 = $_REQUEST["mortgage_late_1"];
			  $mortgage_behind_2 = $_REQUEST["mortgage_behind_2"];
			  $mortgage_late_2 = $_REQUEST["mortgage_late_2"];
			  $lien_title_problem = $_REQUEST["lien_title_problem"];
			  $explain_lien_title = $_REQUEST["explain_lien_title"];
			  $foreclosure_notice = $_REQUEST["foreclosure_notice"];
			  $foreclosure_sale_date = $_REQUEST["foreclosure_sale_date"];
			  $foreclosure_sale_when = $_REQUEST["foreclosure_sale_when"];
			  $asking_for_house = $_REQUEST["asking_for_house"];
			  $house_appraise = $_REQUEST["house_appraise"];
			  $how_soon_to_sell = $_REQUEST["how_soon_to_sell"];
			  $least_to_accept = $_REQUEST["least_to_accept"];
			  $hear_about_us = $_REQUEST["hear_about_us"];
			  $comments = $_REQUEST["comments"];
 
			  $body = "From: $name\n E-mail: $email\n Phone: $phone\n Property Address: $property_address\n Property City: $property_city\n Property State: $property_state\n Zip: $property_zip\n Listed with Realtor?: $listed\n Why are you selling? $why_sell\n Property is: $property_is\n Property type: $property_type\n Age of house: $house_age\n Square footage: $square_footage\n Garage: $garage\n Number of Bedrooms: $bedrooms\n Number of Baths: $bathrooms\n Overall condition of the house: $condition\n What repairs are needed? $repairs\n Any upgrades or remodeling needed? $upgrades\n Age/Condition of Roof: $roof_age\n Mortgage Information:\n 1st mortgage balance: $mortgage_bal_1\n 1st mortgage payment amount: $mortgage_pay_1\n 2nd mortgage balance: $mortgage_bal_2\n 2nd mortgage payment amount: $mortgage_pay_2\n What is the balance of all mortgages combined? $bal_combined\n What is the combined monthly payment on all mortgages? $payment_combined\n Are all mortgage payments current: $mort_pay_current\n If payments are not current how far behind are they? $payments_behind\n 1st Mortgage Amount behind: $mortgage_behind_1\n 1st Mortgage num. of payments late: $mortgage_late_1\n 2nd Mortgage Amount behind: $mortgage_behind_2\n 2nd Mortgage num. of payments late: $mortgage_late_2\n Any Liens and or Title problems? $lien_title_problem\n If yes, please explain: $explain_lien_title\n Have you been sent a foreclosure notice? $foreclosure_notice\n If yes, has the foreclosure sale date been set? $foreclosure_sale_date\n If so, when? $foreclosure_sale_when\n How much are you asking for your house? $asking_for_house\n If we were to have the house appraised, what do you think it would appraise for? $house_appraise\n How soon do you need to sell? $how_soon_to_sell\n If we could pay all cash and close quickly, what is the least amount you could accept? $least_to_accept\n How did you hear about us? $hear_about_us\n Additional Comments: $comments";
 
			  echo "$name, thank you for submitting your property information to Jig Buys Homes.  Will be contacting you shortly.  Have a great day!";
 
			  mail($to, $subject, $body, $headers);
			  ?>