waiverprovider.com
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184.168.224.165
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URL:
http://waiverprovider.com/newsletterform.html
Submission: On June 20 via api from US — Scanned from DE
Submission: On June 20 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: contactForm — POST http://www.mycontactform.com/sendform/sendform.php
<form name="contactForm" method="post" action="http://www.mycontactform.com/sendform/sendform.php">
<input name="user" type="hidden" id="user" value="clearchoice07"><input name="formid" type="hidden" id="formid" value="289826">
<table width="100%" style="border: 10px solid #990000; margin: 0; padding: 0; background-color: #FFFFFF;">
<tbody>
<tr>
<td>
<table width="100%" border="0" cellspacing="0" cellpadding="5">
<tbody>
<tr bgcolor="">
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><b><i> Subject:<font color="#FF0000"> *</font></i></b></font>
</td>
<td style="border-bottom: 5px solid #000000;"><select name="subject" id="subject">
<option value="Sign Up For Our Free Newsletter">Sign Up For Our Free Newsletter</option>
<option value="Add My Company to WaiverProvider.com">Add My Company to WaiverProvider.com</option>
</select></td>
</tr>
<tr>
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><b><i> E-mail Address:<font color="#FF0000"> *</font></i></b></font>
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<td style="border-bottom: 5px solid #000000;"><input name="email" type="text" id="email" size="20" maxlength="100"></td>
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<tr bgcolor="">
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><b><i>Company Name</i></b></font>
</td>
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><input name="q[1]" type="text" value="" size="50" maxlength=""></font>
</td>
</tr>
<tr bgcolor="">
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><b><i>Phone Number</i></b></font>
</td>
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><input name="q[2]" type="text" value="" size="50" maxlength=""></font>
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<tr bgcolor="">
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><b><i>Contact Persons Name</i></b></font>
</td>
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><input name="q[3]" type="text" value="" size="50" maxlength=""></font>
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<tr bgcolor="">
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><b><i>comments</i></b></font>
</td>
<td style="border-bottom: 5px solid #000000;">
<font color="#000000" size="2" face="Arial"><input name="q[4]" type="text" value="" size="50" maxlength=""></font>
</td>
</tr>
<tr>
<td colspan="2"><input name="submit" type="submit" value="Submit"> <input name="reset" type="reset" value="Reset"> <input type="button" value="Print" onclick="window.print()"> </td>
</tr>
<tr>
<td>
<font color="#FF0000" size="1" face="Verdana, Arial, Helvetica, sans-serif"><b>*</b></font>
<font size="1" face="Verdana, Arial, Helvetica, sans-serif">Required</font>
</td>
<td align="right"></td>
</tr>
</tbody>
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</tbody>
</table>
</form>Text Content
WAIVERPROVIDER.COM TRUE CHOICE * Home * SupportCoordinators.Com * FL Group Homes * MedicaidWaiver.org * Advertise > SIGN UP FOR OUR FREE NEWSLETTER! > > Please fill out the form and we will add > you to our list of newsletter subscribers. WaiverProvider.Com sends out > monthly newsletters & other health care information > to thousands of people all across Florida. > We want to help keep you informed. > > call Aaron Nangle if you need help > > 727-841-8943 Subject: *Sign Up For Our Free NewsletterAdd My Company to WaiverProvider.com E-mail Address: *Company Name Phone Number Contact Persons Name comments * Required > GET YOUR COMPANY LISTED > > Call 727-841-8943 to find out how. > > Waiver Providers, you can add your listing even if you don't have a website. > We provide a free one page "web flyer" with your membership. > > Learn About Our Advertising Plans Not a publication of The Agency For Persons With Disabilities * Check it out! * Providers Wanted * SupportCoordinators.Com * Our Newsletter * Includes FSL Waiver * Waiver Services by Category * *Adult Day Training * Adult Dental * *Behavior Analysis * *Behavior Assistant * Companion * *Consumable & Durable Medical * Dietitian * *Emergency Response * *Environmental Modifications * *In Home Supports * Medication Review * Nursing * Personal Care Assistance * Residential Habilitation * *Respite * Specialized Mental Health * *Support Coordination * Supported Employment * *Supported Living * Therapies * *Transportation * More Services * Adaptive Equipment * Wheelchairs * Assisted Living Facilities * Services For providers * Billing Agents * Computer Programs * Support Coordinators Message Board * Resources Message Board * Tools and Resources * For Families * Legal * Rights * Health * Education * Interviewing Providers * Types of Services * Day Activities * Living Options * Medical and Dental * Well Being * Contact * Contact Us * Advertise * Disclaimer * Important Links * The Agency For Persons With Disabilities * The Family Cafe * The Family Care Council * Delmarva * The Florida Developmental Disabilities Council Design by Aaron Nangle of Clear Choice Web Solutions Inc.