Billing

[select name="variable_1" value="Ambassador Drive|Rochester|Plymouth|Long Lake Rd"] [select name="variable_2" value="Living Room|Cocktail Room|Sports Bar|Master Bedroom"] [textarea name="variable_1" default="Enter Item"]. [select name="variable_3" value="Scalamandre|Kneedler Fauchere|Schumacher"] [select name="variable_4" value="Quote #:|Quote|Proforma #:|Estimate #:|Ref #:| Sales Order #:"] [text name="variable_2" default="Enter #"] on [date name="variable_3" default="12/30/2019"] for [text name="variable_4" default=""] yards of the following:

Name: [text name="variable_5" default="sample text"]
Item #: [text name="variable_6" default="sample text"]
Color: [text name="variable_7" default="sample text"]
Width: [text name="variable_8" default="sample text"]
Repeat: [text name="variable_9" default="sample text"]
Content: [text name="variable_10" default="sample text"]

[checkbox name="variable_1" value="Shipping to be determined and billed separately."]

[checkbox name="variable_2" value="Lead Time: In Stock"]

Billed [select name="variable_11" value="100%|50%"]