is_valid) { $msg = "The Captcha code wasn't entered correctly. Please try it again."; } else if(isset($_POST['Health_Info']) && $_POST['Health_Info'] != '') { if(strstr($_POST['Health_Info'],'http://') || strstr($_POST['Health_Info'],'https://') || strstr($_POST['Health_Info'],'www.')) { $msg = "You can not add URLs in Important Health Info Content."; } else { include('mailer/disability_mailer.php'); header('Location: thankyou.htm'); die(); } } else { include('mailer/disability_mailer.php'); header('Location: thankyou.htm'); die(); } } $CustName = $_POST['CustName']; $Telephone = $_POST['Telephone']; $Email = $_POST['Email']; $BestTime = $_POST['BestTime']; $Note = $_POST['Note']; ?> The Dearborn Agency, Inc.
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Disability Proposal Request Form

The Dearborn Agency, Inc.
Fax: # 877-210-5837
Click here to print/download this form


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