<form action="http://www.bubela-associates.com/buying.php?

submit" method="post">

<input type="hidden" name="buyersform" value="true"><input class="hidden"

name="email" value="" autocomplete="off"> <input class="hidden" name="first_name"
value="" autocomplete="off"><input class="hidden" name="last_name" value=""
autocomplete="off"><fieldset><h4>Your Contact Information</h4>

<div class="field x6">

<label>First Name <small class="required">*</small></label>
<br><input name="onc5khko" value="" required></div>

<div class="field x6 last">

<br></b><label>Last Name <small class="required">*</small></label>
<br><input name="sk5tyelo" value="" required></div>

<div class="field x6">

<br><label>Email <small class="required">*</small></label>
<input type="email" name="mi0moecs" value="" required><small></small>
</div>

<div class="field x6 last">

<label>Phone No.</label>
<input type="tel" name="telephone" value=""></div>

<div class="field x6">

<label>Mobile No.</label>
<input type="tel" name="fm-mobile" value=""></div>

<div class="field x6">

<label>Address <small class="required">*</small></label>
<br> <input name="fm-addr" value="" required></div>

<div class="field x6 last">

<br><label>City <small class="required">*</small></label>
<br><input name="fm-town" value="" required></div>

<div class="field x6">

<br><label>State</label>
<br><input name="fm-state" value=""></div>

<div class="field x6 last">

<br><label>Zip Code</label>
<br><input name="fm-postcode" value=""></div>

</fieldset><fieldset><h4>Property Information</h4>

<div class="field x6">

<label>Number of Bedrooms </label>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<select
name="bedrooms"><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><option
value="6">6</option><option value="7+">7+</option></select></div>

<div class="field x6 last">

<br><label>Number of Bathrooms</label>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
<select name="bathrooms"><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><option value="6">6</option><option
value="7+">7+</option></select></div>

<div class="field x6">

<br><label>Square Feet</label>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<select name="square_feet"><option
value="Less than 1000">&lt; 1000</option><option value="1000 - 1500">1000 -
1500</option><option value="1500 - 2000">1500 - 2000</option><option value="2000 -
2500">2000 - 2500</option><option value="2500 - 3000">2500 - 3000</option><option
value="3000 - 3500">3000 - 3500</option><option value="3500 - 4000">3500 -
4000</option><option value="4000 - 4500">4000 - 4500</option><option value="4500 -
5000">4500 - 5000</option><option value="5000 - 6000">5000 - 6000</option><option
value="6000 - 7000">6000 - 7000</option><option value="7000 - 8000">7000 -
8000</option><option value="8000 - 9000">8000 - 9000</option><option value="9000 -
10,000">9000 - 10,000</option><option value="10,000 +">10,000
+</option></select></div>

<div class="field x6 last">

<br><label>Contact You By</label>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;<select
name="contact_you_how"><option value="Email">Email</option><option
value="Phone">Phone</option><option value="Mobile">Mobile</option><option
value="Fax">Fax</option></select></div>

<div class="field x12">

<br><label>Price Range</label>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;<select
name="price_range"><option value="Less than $300,000">Less than
$300,000</option><option value="$300,000 - $500,000">$300,000 -
$500,000</option><option value="$500,000 - $700,000">$500,000 -
$700,000</option><option value="$700,000 - $900,000">$700,000 -
$900,000</option><option value="$900,000 - $1,000,000">$900,000 -
$1,000,000</option><option value="$1,000,000 - $2,000,000">$1,000,000 -
$2,000,000</option><option value="Over $5,000,000">Over
$2,000,000</option></select></div>

</fieldset><fieldset><br><h4>Moving Details</h4>

<div class="field x6">

<label>When do you want to move?</label>
<br> <select name="move_when"><option value="">Choose</option><option
value="Less than 30 days">Less than 30 days</option><option value="1 Month">1
Month</option><option value="2 Months">2 Months</option><option value="3 Months">3
Months</option><option value="4 Months +">4 Months +</option></select></div>

<div class="field x6 last">

<br><label>When did you start looking?</label>
<br><select name="length_looking"><option
value="">Choose</option><option value="Less than 30 days">Less than 30
days</option><option value="1 Month">1 Month</option><option value="2 Months">2
Months</option><option value="3 Months">3 Months</option><option value="4 Months
+">4 Months +</option></select></div>

<div class="field x6">

 <br><label>Where would you like to own?</label>
<input name="where_own" id="where_own" size="28" value=""></div>

<div class="field x6 last">

<br><label>Are you currently with an agent?</label>
<br> <select name="working_with_agent"><option
value="">Choose</option><option value="Yes">Yes</option><option
value="No">No</option></select></div>

<div class="field x12">

<br><label>Message</label>
<textarea cols="32" rows="8" name="comments"></textarea></div>

</fieldset><div class="btnset">
<button type="submit" class="positive"> Submit</button>
</div>

</form>
</div></p>

<div id="comments" class="comments-area">

</div> <!-- .comments-area --> </article>
</section>
</div> <!-- #main -->
</div>
<!-- end .container -->
</div>