<html>
<head>
<title>Credit Repair Form</title>
<style>
body {
background-color: #333;
color: #fff;
font-family: Arial, sans-serif;
}
h1, h2 {
color: #66c2a5;
margin-bottom: 0;
}
input, label, select, textarea, button {
color: #fff;
}
input[type=submit] {
background-color: #66c2a5;
border: none;
color: white;
padding: 12px 24px;
border-radius: 4px;
font-size: 16px;
cursor: pointer;
transition: background-color 0.3s ease;
}
input[type=submit]:hover {
background-color: #8ed1bf;
}
.form-container {
background-color: #222;
max-width: 800px;
margin: 40px auto;
padding: 20px;
box-shadow: 0px 0px 10px rgba(0,0,0,0.1);
border-radius: 4px;
line-height: 1.5em;
}
.alert {
background-color: #444;
border: 1px solid #66c2a5;
margin-bottom: 20px;
padding: 10px 20px;
border-radius: 4px;
color: #66c2a5;
}
</style>
</head>
<body>
<div class="form-container">
<h1>Welcome to Our AI-Powered Credit Repair Company</h1>
<p>Our company is thrilled to offer innovative credit repair services that use the latest in artificial intelligence technologies. With our cutting-edge approach to credit repair, we guarantee to make significant and rapid improvements to your credit score in just 2-3 weeks.</p>
<p>Using our AI algorithms, we analyze your credit reports to identify errors, disputes, and other issues that could be holding you back. Our team of experts will work closely with you to address these problems, negotiate with creditors, and implement actionable solutions that will help you achieve your financial goals.</p>
<div class="alert">
<p><strong>Important:</strong> Please make sure to enter accurate information in the form below to ensure the best results from our credit repair services.</p>
</div>
<form action="process-form.php" method="post">
<h2>Personal Information</h2>
<label for="name">Full Name:</label><br>
<input type="text" name="name" id="name" autocomplete="off" required><br>
<label for="email">Email Address:</label><br>
<input type="email" name="email" id="email" autocomplete="off" required><br>
<label for="phone">Phone Number:</label><br>
<input type="tel" name="phone" id="phone" autocomplete="off" required><br>
<label for="address">Mailing Address:</label><br>
<input type="text" name="address" id="address" required><br>
<label for="city">City:</label><br>
<input type="text" name="city" id="city" required><br>
<label for="state">State:</label><br>
<select name="state" id="state" required>
<option value="">Select State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select><br>
<label for="zip">Zip Code:</label><br>
<input type="text" name="zip" id="zip" required><br>
<label for="ssn">Social Security Number:</label><br>
<input type="password" name="ssn" id="ssn" required><br>
<label for="credit-score">Current Credit Score:</label><br>
<input type="number" name="credit-score" id="credit-score" required><br>
<h2>Message</h2>
<label for="message">Tell us more about your credit situation (maximum 300 characters):</label><br>
<textarea name="message" id="message" rows="10" cols="50" maxlength="300" required></textarea><br><br>
<input type="submit" value="Submit Form">
</form>
</div>
</body>
</html>
