<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">

<form action="https://www.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST">

<input type=hidden name="oid" value="00D46000000ri13">
<input type=hidden name="retURL" value="http://www.breadoflifemission.org/">

<label for="company">Company</label><input  id="company" maxlength="40" name="company" size="20" type="text" /><br><br>

<label for="first_name">First Name</label><input  id="first_name" maxlength="40" name="first_name" size="20" type="text" /><br><br>

<label for="last_name">Last Name</label><input  id="last_name" maxlength="80" name="last_name" size="20" type="text" /><br><br>

<label for="phone">Phone</label><input  id="phone" maxlength="40" name="phone" size="20" type="text" /><br><br>

<label for="email">Email</label><input  id="email" maxlength="80" name="email" size="20" type="text" /><br><br>

<label for="street">Street</label><textarea name="street"></textarea><br><br>

<label for="city">City</label><input  id="city" maxlength="40" name="city" size="20" type="text" /><br><br>

<label for="state">State/Province</label><input  id="state" maxlength="20" name="state" size="20" type="text" /><br><br>

<label for="zip">Zip</label><input  id="zip" maxlength="20" name="zip" size="20" type="text" /><br><br><br><br>



Clothes:<input  id="00N46000009gbTb" name="00N46000009gbTb" type="checkbox" value="1" /><br><br>

Shoes:<input  id="00N46000009gbTg" name="00N46000009gbTg" type="checkbox" value="1" /><br><br>

Food:<input  id="00N46000009gbTl" name="00N46000009gbTl" type="checkbox" value="1" /><br><br>

Other:<input  id="00N46000009gbTq" name="00N46000009gbTq" type="checkbox" value="1" /><br><br>

If Other, describe:<textarea  id="00N46000009gbTv" name="00N46000009gbTv" type="text" wrap="soft"></textarea><br><br>

If Clothing, new or used?:<select  id="00N46000009gbU0" name="00N46000009gbU0" title="If Clothing, new or used?"><option value="">--None--</option><option value="New">New</option>
<option value="Used">Used</option>
</select><br><br>

Total Weight:<input  id="00N46000009gbU5" name="00N46000009gbU5" size="20" type="text" /><br><br>

Fair Market Value:<input  id="00N46000009gbUA" name="00N46000009gbUA" size="20" type="text" /><br><br>

Donation Description:<textarea  id="00N46000009gbVXEAY" name="00N46000009gbVXEAY" rows="25" type="text" wrap="soft"></textarea><br><br>

<input type=hidden name="recordType" value="01246000000hQOG">

<input type="submit" name="submit">

</form>