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<input type='hidden' class='gforms-pum' value='{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}' />
<div class='gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_3_1' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_3_1' >Email Address</label><div class='ginput_container ginput_container_email'>
<input name='input_1' id='input_3_1' type='text' value='' class='medium' aria-invalid="false" />
</div></li><li id='field_3_2' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Locations</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_2'><li class='gchoice_3_2_1'>
<input name='input_2.1' type='checkbox' value='Fort Myers' id='choice_3_2_1' />
<label for='choice_3_2_1' id='label_3_2_1'>Fort Myers, Fort Myers Beach, Sanibel & Captiva</label>
</li><li class='gchoice_3_2_2'>
<input name='input_2.2' type='checkbox' value='Sarasota' id='choice_3_2_2' />
<label for='choice_3_2_2' id='label_3_2_2'>Sarasota, Siesta Key, Longboat, Lido, & Venice</label>
</li><li class='gchoice_3_2_3'>
<input name='input_2.3' type='checkbox' value='Naples' id='choice_3_2_3' />
<label for='choice_3_2_3' id='label_3_2_3'>Naples, Marco Island, Everglades</label>
</li></ul></div></li><li id='field_3_3' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_3_3' ></label><div id='input_3_3' class='ginput_container ginput_recaptcha' data-sitekey='6LeAjKsUAAAAAD72VNHUsfFGdrDsUtYUWAB67i6n' data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'></div></li>
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<input type='hidden' class='gform_hidden' name='is_submit_3' value='1' />
<input type='hidden' class='gform_hidden' name='gform_submit' value='3' />
<input type='hidden' class='gform_hidden' name='gform_unique_id' value='' />
<input type='hidden' class='gform_hidden' name='state_3' value='WyJbXSIsIjFjZTA0OTU3N2MzMjA5N2M1OWE4Yzk4ZTAyMzU0MjJmIl0=' />
<input type='hidden' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' />
<input type='hidden' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' />
<input type='hidden' name='gform_field_values' value='' />
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</form>
</div>
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