Contact Information

Planet Access
c/o Kenneth Bauer
39660 Highland Drive
Polson, MT 59860

1-406-239-2705
 

 

Information Request Form

'; $_REQUEST['product'] = stripslashes(strip_tags(trim($_REQUEST['product']))); $_POST['requested_info'] = $_REQUEST['product']; $request_content .= input_text_s('requested_info', $_POST, $form, $user_message); $request_content .= input_text_s('name', $_POST, $form, $user_message); $request_content .= input_textarea_s('address', $_POST, $form, $user_message); $request_content .= input_text_s('city', $_POST, $form, $user_message); $request_content .= input_text_s('state', $_POST, $form, $user_message); $request_content .= input_text_s('zip', $_POST, $form, $user_message); $request_content .= input_text_s('country', $_POST, $form, $user_message); $request_content .= input_text_s('phone', $_POST, $form, $user_message); $request_content .= input_text_s('website', $_POST, $form, $user_message); $request_content .= input_text_s('email', $_POST, $form, $user_message); $request_content .= input_textarea_s('comments', $_POST, $form, $user_message); $request_content .= ' '; $request_content .= input_submit_s('submit', 'Submit Request'); $request_content .= '

To receive additional information, please fill out the form below and click "Submit Request".
Are you interested in?
A catalog
Lifts
Access Chairs
Swim Platforms

Would you like to be added to our catalog mailing list?

'; echo $request_content; ?>