Submission of  #date#  at  #time# [EST] 
name: #name# <br>
address: #address# <br>
city: #city# <br>
state: #state# <br>
zip: #zip# <br>
from: #Email# <br>
hphone: #hphone# <br>
date of birth: #dob# <br>
race: #race# <br>
find?: #find# <br>
phone: #wphone# <br>
employer: #employmt# <br>
city: #birthcity# <br>
county: #birthcounty# <br>
state: #birthstate# <br>
birthtime: #birthtime# <br>
weight: #weight# <br>
baptized?: #baptized# <br>
religion?: #religion# <br>
hospital: #hospital# <br>
dr: #DR# <br>
address: #hospaddress# <br>
cityst: #hospcityst# <br>
city: #placedcity# <br>
cnty: #placedcnty# <br>
placedst: #placedst# <br>
agency: #placemtagency# <br>
address: #agcyaddress# <br>
socworker: #socworker# <br>
contact: #lastcontact# <br>
court: #court# <br>
nonidrecd: #nonidrecd#  <br>
coorrecd: #coorrecd#  <br>
birthname: #birthname# <br>
birthmother: #birthmother# <br>
birthfather: #birthfather# <br>
adoptname: #adoptname# <br>
adoptfather: #adoptfather# <br>
adoptmother: #adoptmother# <br>