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[contact-form to=’customerservice@couleeinternet.com’ subject=’New Customer Lead’][contact-field label=’Service’ type=’select’ options=’Wired w/ ZIPP ($50 install / $55/mo),Wired w/o ZIPP ($110 install / $55/mo),Wireless w/ no contract ($250 install / $55/mo),Wireless w/ 2 yr contract ($110 install / $55/mo)’/][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Phone’ type=’text’/][contact-field label=’Address’ type=’textarea’/][contact-field label=’How did you hear about us?’ type=’textarea’/][/contact-form]