<form method=”post” action=”https://ricknguyenz.xyz/wp-content/plugins/textly/remotesubmit.php”>
<input type=”hidden” name=”Redirect” id=”Redirect” value=”https://glennreview.com/”>
<table style=”padding:0px; border:0px;”>
<tbody><tr id=”NameLine”>
<td><span id=”NameFieldTag”>Name:</span></td><td><input type=”text” name=”name” id=”Name”></td>
</tr>
<tr>
<td><span id=”FieldTag”>Phone Number:</span></td><td><input type=”text” name=”email” id=”Email” required=””></td>
</tr>
<tr>
<td colspan=”2″><font style=”font-size:14px; color:#990000;”>Please include your area code</font></td>
</tr>
<tr>
<td colspan=”2″><input id=”SubmitTag” type=”submit” value=”Submit”></td>
</tr>
</tbody></table>
</form>

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