<?php
include('config.php');
// fetching admin email where mail will send

$sql ="SELECT emailId from tblemail";
$query = $dbh -> prepare($sql);
$query->execute();
$results=$query->fetchAll(PDO::FETCH_OBJ);
if($query->rowCount() > 0):
foreach($results as $result):
$adminemail=$result->emailId;
endforeach;
endif;
if(isset($_POST['submit']))
{
// getting Post values	
$name=$_POST['name'];
$phoneno=$_POST['phonenumber'];
$email=$_POST['emailaddres'];
$subject=$_POST['subject'];
$message=$_POST['message'];
$message2=$_POST['message2'];
$message3=$_POST['message3'];
$message4=$_POST['message4'];
$message5=$_POST['message5'];
$message6=$_POST['message6'];
$message7=$_POST['message7'];
$message8=$_POST['message8'];
$loantype=$_POST['loantype'];
$state2=$_POST['state2'];
	
$f1=$_POST['f1'];
$f2=$_POST['f2'];
$f3=$_POST['f3'];
$f4=$_POST['f4'];
$f5=$_POST['f5'];
$f6=$_POST['f6'];
$f7=$_POST['f7'];
$f8=$_POST['f8'];
$f9=$_POST['f9'];
$f10=$_POST['f10'];
$f11=$_POST['f11'];
$f12=$_POST['f12'];
$f13=$_POST['f13'];
$f14=$_POST['f14'];
$f15=$_POST['f15'];
$f16=$_POST['f16'];
$f17=$_POST['f17'];
$f18=$_POST['f18'];
$f19=$_POST['f19'];
$f20=$_POST['f20'];
$f21=$_POST['f21'];
$f22=$_POST['f22'];
$f23=$_POST['f23'];
$f24=$_POST['f24'];
$f25=$_POST['f25'];
$f26=$_POST['f26'];
$f27=$_POST['f27'];
$f28=$_POST['f28'];


	
$uip = $_SERVER ['REMOTE_ADDR'];
$isread=0;
// Insert quaery
$sql="INSERT INTO  tblcontactdata(FullName,PhoneNumber,EmailId,Subject,Message,Message2,Message3,Message4,Message5,Message6,Message7,Message8,state2,loantype,f1,f2,f3,f4,f5,f6,f7,f8,f9,f10,f11,f12,f13,f14,f15,f16,f17,f18,f19,f20,f21,f22,f23,f24,f25,f26,f27,f28,UserIp,Is_Read) VALUES(:fname,:phone,:email,:subject,:message,:message2,:message3,:message4,:message5,:message6,:message7,:message8,:state2,:loantype,:f1,:f2,:f3,:f4,:f5,:f6,:f7,:f8,:f9,:f10,:f11,:f12,:f13,:f14,:f15,:f16,:f17,:f18,:f19,:f20,:f21,:f22,:f23,:f24,:f25,:f26,:f27,:f28,:uip,:isread)";
$query = $dbh->prepare($sql);
// Bind parameters
$query->bindParam(':fname',$name,PDO::PARAM_STR);
$query->bindParam(':phone',$phoneno,PDO::PARAM_STR);
$query->bindParam(':email',$email,PDO::PARAM_STR);
$query->bindParam(':subject',$subject,PDO::PARAM_STR);
$query->bindParam(':message',$message,PDO::PARAM_STR);
$query->bindParam(':message2',$message2,PDO::PARAM_STR);
$query->bindParam(':message3',$message3,PDO::PARAM_STR);
$query->bindParam(':message4',$message4,PDO::PARAM_STR);
$query->bindParam(':message5',$message5,PDO::PARAM_STR);
$query->bindParam(':message6',$message6,PDO::PARAM_STR);
$query->bindParam(':message7',$message7,PDO::PARAM_STR);
$query->bindParam(':message8',$message8,PDO::PARAM_STR);
$query->bindParam(':loantype',$loantype,PDO::PARAM_STR);
$query->bindParam(':state2',$state2,PDO::PARAM_STR);
$query->bindParam(':f1',$f1,PDO::PARAM_STR);
$query->bindParam(':f2',$f2,PDO::PARAM_STR);
$query->bindParam(':f3',$f3,PDO::PARAM_STR);
$query->bindParam(':f4',$f4,PDO::PARAM_STR);
$query->bindParam(':f5',$f5,PDO::PARAM_STR);
$query->bindParam(':f6',$f6,PDO::PARAM_STR);
$query->bindParam(':f7',$f7,PDO::PARAM_STR);
$query->bindParam(':f8',$f8,PDO::PARAM_STR);
$query->bindParam(':f9',$f9,PDO::PARAM_STR);
$query->bindParam(':f10',$f10,PDO::PARAM_STR);
$query->bindParam(':f11',$f11,PDO::PARAM_STR);
$query->bindParam(':f12',$f12,PDO::PARAM_STR);
$query->bindParam(':f13',$f13,PDO::PARAM_STR);
$query->bindParam(':f14',$f14,PDO::PARAM_STR);
$query->bindParam(':f15',$f15,PDO::PARAM_STR);
$query->bindParam(':f16',$f16,PDO::PARAM_STR);
$query->bindParam(':f17',$f17,PDO::PARAM_STR);
$query->bindParam(':f18',$f18,PDO::PARAM_STR);
$query->bindParam(':f19',$f19,PDO::PARAM_STR);
$query->bindParam(':f20',$f20,PDO::PARAM_STR);
$query->bindParam(':f21',$f21,PDO::PARAM_STR);
$query->bindParam(':f22',$f22,PDO::PARAM_STR);
$query->bindParam(':f23',$f23,PDO::PARAM_STR);
$query->bindParam(':f24',$f24,PDO::PARAM_STR);
$query->bindParam(':f25',$f25,PDO::PARAM_STR);
$query->bindParam(':f26',$f26,PDO::PARAM_STR);
$query->bindParam(':f27',$f27,PDO::PARAM_STR);
$query->bindParam(':f28',$f28,PDO::PARAM_STR);
	
$query->bindParam(':uip',$uip,PDO::PARAM_STR);
$query->bindParam(':isread',$isread,PDO::PARAM_STR);
$query->execute();
$lastInsertId = $dbh->lastInsertId();
if($lastInsertId)
{
//mail function for sending mail
$to=$adminemail; 
$headers .= "MIME-Version: 1.0"."\r\n";
$headers .= 'Content-type: text/html; charset=iso-8859-1'."\r\n";
$headers .= 'From:Brick & Mortar Funding Application Submission<apply@brickandmortarfunding.com>'."\r\n";
$ms.="<html></body><div>
<div><b>Name:</b> $name,</div>
<div><b>Phone Number:</b> $phoneno,</div>

<div><b>Email:</b> $email,</div>";
$ms.="<div style='padding-top:8px;'><b>
<div><b>https://brickandmortarfunding.com/</b><br/></div>
</b></div><div></div></body></html>";
mail($to,$subject,$ms,$headers);




echo "<script>alert('Your Application submitted successfully. You will be contacted within 1-2 business days of your submission by a Brick & Mortar Funding Representative.');</script>";
}
else 
{
echo "<script>alert('Something went wrong. Please try again');</script>";
}


}


?>
<!DOCTYPE HTML>
<html dir="ltr" lang="en-US">
<head>

	<meta name="author" content="BrickandMortarFunding" />

	<!-- Stylesheets
	============================================= -->
	<link href="https://fonts.googleapis.com/css?family=Lato:300,400,400i,700|Raleway:300,400,500,600,700|Crete+Round:400i" rel="stylesheet" type="text/css" />
	<link rel="stylesheet" href="css/bootstrap.css" type="text/css" />
	<link rel="stylesheet" href="style.css" type="text/css" />
	<link rel="stylesheet" href="css/dark.css" type="text/css" />
	<link rel="stylesheet" href="css/font-icons.css" type="text/css" />
	<link rel="stylesheet" href="css/animate.css" type="text/css" />
	<link rel="stylesheet" href="css/magnific-popup.css" type="text/css" />

	<link rel="stylesheet" href="css/responsive.css" type="text/css" />
	<meta name="viewport" content="width=device-width, initial-scale=1" />

	<!--favicon icon-->
    <link rel="icon" type="image/ico" href="images/favicon.ico">

	<!-- Document Title
	============================================= -->
	<title>Loan Application | Brick &amp; Mortar Funding</title>

</head>
<body class="stretched">

	<!-- Document Wrapper
	============================================= -->
	<div id="wrapper" class="clearfix">

		<!-- Header
		============================================= -->
		<header id="header" class="static-sticky  ">

			<div id="header-wrap">

				<div class="container clearfix">

					<div id="primary-menu-trigger"><i class="icon-reorder"></i></div>

					<!-- Logo
					============================================= -->
					<div id="logo">
						<a href="index.html" class="standard-logo" data-dark-logo="images/logo-dark.png"><img src="images/logo.png" alt="Brick &amp; Mortar Funding"></a>
						<a href="index.html" class="retina-logo" data-dark-logo="images/logo-dark@2x.png"><img src="images/logo@2x.png" alt="Brick &amp; Mortar Funding"></a>
					</div><!-- #logo end -->

					<!-- Primary Navigation
					============================================= -->
					<nav id="primary-menu">

						<ul>
							<li><a href="about.html"><div>About</div></a></li>
							<li><a href="our-solutions.html">
										<div>Our Solutions</div>
									</a>
									<ul>
										<li><a href="our-solutions.html#loans">
												<div>Loans</div>
											</a></li>
										<li><a href="our-solutions.html#advantages">
												<div>Advantages</div>
											</a></li>
										<li><a href="our-solutions.html#process">
												<div>Lending Process</div>
											</a></li>
										<li><a href="our-solutions.html#partners">
												<div>Broker Partners</div>
											</a></li>
									</ul>
								</li>
							<li><a href="faqs.html"><div>FAQs</div></a></li>
							<li><a href="contact.html"><div>Contact Us</div></a></li>
							<li><a href="apply.php"><div>Apply</div></a></li>
						</ul>
					</nav><!-- #primary-menu end -->

				</div>

			</div>

		</header><!-- #header end -->

		<!-- Page Title
		============================================= -->
		<section id="slider" class="slider-element clearfix" style="height: 200px; background: url('images/brick-bg-light.jpg') center center no-repeat; background-size: cover;">
			<div class="vertical-middle">
				<div class="container clearfix">

					
					<div class="clearfix " style="max-width: 700px;">
				<h1 style="color: ; font-size: 46px; font-weight: 500; text-shadow: 0 7px 10px rgba(0,0,0,0.07), 0 4px 4px rgba(0,0,0,0.2); letter-spacing: 2px; margin-bottom: 1px;" data-animate="fadeInUp">Loan Application</h1>
				
			</div>

				</div>
			</div>

		</section>
		<!-- <section id="page-title">
		
			<div class="container clearfix">
				<h1>Loan Application</h1>
			
				
			</div>
		
		</section> --><!-- #page-title end -->

		<!-- Content
		============================================= -->
		<section id="content">

			<div class="content-wrap">
				
				<div class="container clearfix">
				<div class="col_three_fifth offset-md-2">
					<div class="notopmargin clearfix " >
						<div class="feature-box fbox-small nobottomborder">
	
							<p style="font-size: 18px;">Please complete and submit the loan application below. </p>
							<p>You will be contacted within 1-2 business days of your submission by a Brick &amp; Mortar Funding Representative. </p>
							<p>All application details are transmitted via secure SHA-256 SSL encryption technology (the same standard as a traditional bank) and used by Brick &amp; Mortar Funding only.</p>
						</div>
					</div>
				</div>
				</div>

				<div class="container clearfix">
					

					<!-- Contact Form
					============================================= -->
					<div class="col_half offset-md-3">

						<div class="">
			
							 <form class="nobottommargin" id="template-contactform" name="ContactForm" method="post">

							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputEmail4">Applicant Name(s)<small>*</small></label>
									<input type="text" name="name" class="form-control" id="inputEmail4" placeholder="" required>
								</div>
							</div>
							<div class="form-group">
								<label for="inputAddress">Company or DBA</label>
								<input type="text" name="subject" class="form-control" placeholder="" autocomplete="off">
							</div>
							<div class="form-group">
								<label for="inputAddress2">Home/Business Address<small>*</small></label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="message" placeholder="" required>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="inputCity">City<small>*</small></label>
									<input name="message5" type="text" class="form-control" id="inputCity">
									
								</div>
								<div class="form-group col-md-4">
									<label for="inputState">State<small>*</small></label>
									<select name="message7" id="inputState" class="form-control">
										<option selected>Choose...</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="DC">District Of Columbia</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>
								</div>
								<div class="form-group col-md-2">
									<label for="inputZip">Zip<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="message2" placeholder="" required>
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="">Date of Birth<small>*</small></label>
									<!-- <input type="email" class="form-control" id="inputEmail4" placeholder=""> -->
									<input class="form-control" name="message3" placeholder="" required>
								</div>
								<div class="form-group col-md-6">
									<label for="">Name of Spouse</label>
									<!-- <input type="password" class="form-control" id="inputPassword4" placeholder=""> -->
									<input class="form-control" name="message4" placeholder="" >
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="">Office/Work Phone</label>
									<input type="text" name="phonenumber" class="form-control" placeholder="" maxlength="10" autocomplete="off"> 
									<!-- <textarea class="form-control" name="message5" placeholder="Message5" required></textarea> -->
								</div>
								<div class="form-group col-md-6">
									<label for="inputPassword4">Mobile Phone<small>*</small></label>
									<!-- <input type="password" class="form-control" id="inputPassword4" placeholder=""> -->
									<input class="form-control" name="message6" placeholder="" required>
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputEmail4">Email<small>*</small></label>
									<input type="email" name="emailaddres" class="form-control" placeholder="Example@mail.com" required autocomplete="off">
									<!-- <textarea class="form-control" name="message7" placeholder="Message7" required></textarea> -->
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputEmail4">Members/Officers of Borrowing Entity</label>
									<!-- <input type="email" class="form-control" id="inputEmail4" placeholder=""> -->
									<input class="form-control" name="message8" placeholder="" >
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputEmail4">Requested Loan Amount<small>*</small></label>
									<!-- <input type="email" class="form-control" id="inputEmail4" placeholder=""> -->
									<input class="form-control" name="f1" placeholder="" required>
								</div>
							</div>
							<div class="form-group">
								<label for="inputAddress2">Address of Subject Property<small>*</small></label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f2" placeholder="" required>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="inputCity">City<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f3" placeholder="" required>
								</div>
								<div class="form-group col-md-4">
									<label for="inputState">State<small>*</small></label>
									<select name="state2" id="inputState" class="form-control">
										<option selected>Choose...</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="DC">District Of Columbia</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>
								</div>
								<div class="form-group col-md-2">
									<label for="inputZip">Zip<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f4" placeholder="" required>
								</div>
							</div>
							<div class="form-group col-md-6">
									<label for="inputState">Loan Type<small>*</small></label>
									<select name="loantype" id="inputState" class="form-control">
									<option selected>Choose...</option>
									<option value= Acquisition> Acquisition </option>
									<option value= Rehab> Rehab </option>
									<option value= Bridge> Bridge</option>
									</select>
								 </div>
			
							<div class="form-group">
								<label for="exampleFormControlTextarea1">Please describe the type of property, its current condition and what you plan to do with the loan proceeds</label>
								<!-- <textarea class="form-control" id="exampleFormControlTextarea1" rows="3"></textarea> -->
								<textarea class="form-control" name="f5" placeholder="" ></textarea>
							</div>
							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputEmail4">Estimated Market Value of Property in Current Condition</label>
									<!-- <input type="email" class="form-control" id="inputEmail4" placeholder=""> -->
									<input class="form-control" name="f6" placeholder="" >
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-8">
									<label for="inputCity">Date of Last Appraisal/Market Valuation</label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f7" placeholder="" >
								</div>
								<div class="form-group col-md-4">
									<label for="inputZip">Established Value</label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f8" placeholder="" >
								</div>
							</div>
							<div class="form-group">
								<label for="inputAddress2">Loan to Current Value (Loan Amount/Current Value)</label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f9" placeholder="" >
							</div>
							<div class="form-group">
								<label for="inputAddress2">Estimated Value after improvement or construction</label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f10" placeholder="" >
							</div>
							<div class="form-group">
								<label for="exampleFormControlTextarea1">If the property is currently rented, please include an income and expense breakdown for the property in its current condition and an estimated income and expense breakdown for after the repair or improvement</label>
								<!-- <textarea class="form-control" id="exampleFormControlTextarea1" rows="3"></textarea> -->
								<textarea class="form-control" name="f11" placeholder=""></textarea>
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								<label for="inputAddress2">Anticipated Source of Repayment<small>*</small></label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f12" placeholder="" required>
							</div>
							<div class="form-group">
								<label for="exampleFormControlTextarea1">Below please provide the name and Tax ID or Social Security Number of the borrowers. If the borrower is an entity, please list the principals of the entity who will be personally guaranteeing the loan. Please provide a signed credit report and Background Check Authorization Form for each proposed guarantor.</label>
								<label for="inputCity">Name<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f13" placeholder="" required>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="inputCity">Tax ID<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f14" placeholder="" required>
								</div>
								<div class="form-group col-md-6">
									<label for="inputZip">SSN<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f15" placeholder="" required>
								</div>
							</div>
							<div class="form-group">
								<label for="inputAddress2">Borrower's Attorney Contact Info</label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f16" placeholder="" >
							</div>
							<div class="form-group">
								<label for="inputAddress2">Borrower's Accountant Contact Info</label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f17" placeholder="" >
							</div>
							<div class="form-group">
								<label for="inputAddress2">Borrower's Bank Contact Info<small>*</small></label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f18" placeholder="" required>
							</div>
							<div class="form-group">
								<label for="inputAddress2">Name of Broker</label>
								<!-- <input type="text" class="form-control" id="inputAddress2" placeholder=""> -->
								<input class="form-control" name="f19" placeholder="" >
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="inputCity">Signature of Applicant<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f20" placeholder="" required>
								</div>
								<div class="form-group col-md-6">
									<label for="inputZip">Signature of Co-Applicant</label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f21" placeholder="">
								</div>
							</div>
							<div class="line"></div>
							<h3>Credit Report and Background Check</h3>
							<h3>Authorization Form</h3>
							<p>I hereby authorize Brick and Mortar Funding LLC and its agents (collectively, "Brick and Mortar Funding") to obtain and review my credit report and to investigate my financial condition and credit worthiness. My credit report may be obtained from any credit reporting agency chosen by Brick and Mortar Funding to investigate my background and contact any references I provide.
							<br><br>
							A facsimile or electronic copy of this authorization shall be equivalent of the original and I authorize any third-party to rely on this authorization or a facsimile or electronic copy hereof.
							<br><br> 
							I understand that I may revoke my consent to these disclosures by notifying Brick and Mortar Funding in writing. 
							</p>
							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputCity">Name of Person Giving Authorization<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f22" placeholder="" required>
								</div>
								<div class="form-group col-md-6">
									<label for="inputZip">Date<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f23" placeholder="" required>
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="inputCity">Phone<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f24" placeholder="" required>
								</div>
								<div class="form-group col-md-6">
									<label for="inputZip">SSN<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f25" placeholder="" required>
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-12">
									<label for="inputCity">Address<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f26" placeholder="" required>
								</div>
							</div>
							<div class="form-row">
								<div class="form-group col-md-6">
									<label for="inputCity">Signature<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputCity"> -->
									<input class="form-control" name="f27" placeholder="" required>
								</div>
								<div class="form-group col-md-6">
									<label for="inputZip">Date<small>*</small></label>
									<!-- <input type="text" class="form-control" id="inputZip"> -->
									<input class="form-control" name="f28" placeholder="" required>
								</div>
							</div>
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								<h3>Our Headquarters<span class="subtitle">14 McKenna Commons Court
Greenville, SC 29615</span></h3>
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								<h3>Speak to Us<span class="subtitle">Main (864) 640-4632<br>Fax (864) 729-4847</span></h3>
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