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<form action="http://jotform.com/submit/63062148161" method="POST">

<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td colspan="2" width="150" valign="bottom" >

   YOUR INFORMATION:

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

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  <td width="150" valign="bottom" >

   <label for="q1">Last Name</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q1_LastName" id="q1">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

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  <td width="150" valign="bottom" >

   <label for="q0">First Name</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q0_FirstName" id="q0">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

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  <td width="150" valign="bottom" >

   <label for="q2">Address</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q2_Address" id="q2">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

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  <td width="150" valign="bottom" >

   <label for="q3">City</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q3_City" id="q3">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

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  <td width="150" valign="bottom" >

   <label for="q8">E-mail</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q8_E-mail" id="q8">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q10">Phone Number</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q10_PhoneNumber" id="q10">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q9">Would you like to be contacted with updates on this case?</label>

  </td>

  <td valign="bottom">

   <select name="q9_Wouldyouliketobecontactedwithupdatesonthiscase" id="q9">

    <option></option>

    <option>Yes</option>

    <option>No</option>

   </select>

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td colspan="2" width="150" valign="bottom" >

   CRUELTY INFORMATION:

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q13">Name of person resonsible for abused animal and/or address of animal's location.</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q13_Nameofpersonresonsibleforabusedanimalandoraddressofanimalslocation" id="q13">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q19">How long have you suspected cruelty to this animal?</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q19_Howlonghaveyoususpectedcrueltytothisanimal" id="q19">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q14">Type of Animal </label>

  </td>

  <td valign="bottom">

   <select name="q14_TypeofAnimal" id="q14">

    <option></option>

    <option>Dog(s)</option>

    <option>Cat(s)</option>

    <option>Horse(s)</option>

    <option>Bird(s)</option>

    <option>Pig(s)</option>

    <option>Cow(s)</option>

    <option>Ferret(s)</option>

    <option>Goat(s)</option>

    <option>Other</option>

   </select>

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q22">Color(s), Size, and/or unique characteristics that would make determining the animal easier.</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q22_Colors,Size,andoruniquecharacteristicsthatwouldmakedeterminingtheanimaleasier" id="q22">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q25">If you have contacted the sheriff's department concerning this situation, how long ago did you contact them? Did they visit the owner or the animal (to your knowledge?)</label>

  </td>

  <td valign="bottom">

   <input type="text" size="20" name="q25_Ifyouhavecontactedthesheriffsdepartmentconcerningthissituation,howlongagodidyoucontactthemDidtheyvisittheownerortheanimaltoyourknowledge" id="q25">

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="top"  >

   <label for="q20">Tell us about the animal's situation and the way it is being cruelly treated.</label>

  </td>

  <td valign="bottom">

   <textarea wrap="soft" cols="30" rows="3" name="q20_Tellusabouttheanimalssituationandthewayitisbeingcruellytreated" id="q20"></textarea>

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="bottom" >

   <label for="q23">Do you have pictures of the animal?</label>

  </td>

  <td valign="bottom">

   <select name="q23_Doyouhavepicturesoftheanimal" id="q23">

    <option></option>

    <option>Yes</option>

    <option>No</option>

   </select>

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td width="150" valign="top"  >

   <label for="q26">Anything else you would like to include?...</label>

  </td>

  <td valign="bottom">

   <textarea wrap="soft" cols="30" rows="3" name="q26_Anythingelseyouwouldliketoinclude" id="q26"></textarea>

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

 <tr valign="bottom">

  <td colspan="2" width="150" valign="bottom" >

   Grace's Home would like to thank you for taking the time to help animals. God will bless you for your kindness to his creatures!

  </td>

 </tr>

</table>



<table width="520" cellpadding="5" cellspacing="0">

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  <td width="150" valign="bottom" >

   

  </td>

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  <input type="submit" name="q7_" value="Submit">

  </td>

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</table>



</form>



  

   



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