[et_pb_section bb_built=”1″ fullwidth=”off” specialty=”off”][et_pb_row _builder_version=”3.0.60″ background_position_1=”top_left” background_repeat_1=”no-repeat” background_position_2=”top_left” background_repeat_2=”no-repeat” use_custom_width=”on” custom_width_px=”980px” background_color=”#e02b20″ custom_margin=”||0px|”][et_pb_column type=”1_2″][et_pb_image _builder_version=”3.0.60″ src=”https://www.tankamerica.com/wp-content/uploads/2017/08/GuysGroup.png” show_in_lightbox=”off” url_new_window=”off” use_overlay=”off” sticky=”off” align=”left” always_center_on_mobile=”on” border_style=”solid” force_fullwidth=”off” animation=”off” custom_margin=”|||50px” /][/et_pb_column][et_pb_column type=”1_2″][et_pb_text _builder_version=”3.0.60″ background_layout=”light” text_orientation=”left” border_style=”solid” module_class=”contact-form-head”]

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[/et_pb_text][/et_pb_column][/et_pb_row][et_pb_row _builder_version=”3.0.60″ background_position_1=”top_left” background_repeat_1=”no-repeat” use_custom_width=”on” custom_width_px=”980px” custom_margin=”0px|||” custom_padding=”0px|||”][et_pb_column type=”4_4″][et_pb_code _builder_version=”3.0.60″ module_class=”contact-form”]<h1 class=”text-center”>Customer Information</h1><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><br><!– [et_pb_line_break_holder] –><form method=”POST”><!– [et_pb_line_break_holder] –><div><input type=”hidden” name=”landing-subject” id=”landing-subject” value=”Tank America Contact Us”><input type=”hidden” name=”landing-url” id=”landing-url” value=””></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-email”>Email Address</label><!– [et_pb_line_break_holder] –><input type=”email” class=”form-control” id=”landing-email” name=”landing-email” required=””><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-email”>Confirm Email</label><!– [et_pb_line_break_holder] –><input type=”email” class=”form-control” id=”landing-email” name=”landing-email” required=””><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-email”>Title</label><!– [et_pb_line_break_holder] –><div class=”btn-group btn-group-justified”><!– [et_pb_line_break_holder] –><button type=”button” style=”width:25%;” data-switch-set=”size” data-switch-value=”mini” class=”btn btn-default”>Mr</button><button style=”width:25%;” type=”button” data-switch-set=”size” data-switch-value=”small” class=”btn btn-default”>Miss</button><button style=”width:25%;” type=”button” data-switch-set=”size” data-switch-value=”normal” class=”col-md-3 btn btn-default”>Mrs</button><button style=”width:25%;” type=”button” data-switch-set=”size” data-switch-value=”large” class=”btn btn-default”>Ms</button></div><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-facility”>First Name</label><!– [et_pb_line_break_holder] –><input type=”text” class=”form-control” id=”landing-facility” name=”landing-facility” required=””><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-facility”>Last Name</label><!– [et_pb_line_break_holder] –><input type=”text” class=”form-control” id=”landing-facility” name=”landing-facility” required=””><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-facility”>Date of Birth:</label><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><select id=”DateOfBirthMonth” name=”DateOfBirthMonth”><option value=””>Month</option><!– [et_pb_line_break_holder] –><option value=”1″>January</option><!– [et_pb_line_break_holder] –><option value=”2″>February</option><!– [et_pb_line_break_holder] –><option value=”3″>March</option><!– [et_pb_line_break_holder] –><option value=”4″>April</option><!– [et_pb_line_break_holder] –><option value=”5″>May</option><!– [et_pb_line_break_holder] –><option value=”6″>June</option><!– [et_pb_line_break_holder] –><option value=”7″>July</option><!– [et_pb_line_break_holder] –><option value=”8″>August</option><!– [et_pb_line_break_holder] –><option value=”9″>September</option><!– [et_pb_line_break_holder] –><option value=”10″>October</option><!– [et_pb_line_break_holder] –><option value=”11″>November</option><!– [et_pb_line_break_holder] –><option value=”12″>December</option><!– [et_pb_line_break_holder] –></select><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><select id=”DateOfBirthDay” name=”DateOfBirthDay”><option value=””>Day</option><!– [et_pb_line_break_holder] –><option value=”1″>1</option><!– [et_pb_line_break_holder] –><option value=”2″>2</option><!– [et_pb_line_break_holder] –><option value=”3″>3</option><!– [et_pb_line_break_holder] –><option value=”4″>4</option><!– [et_pb_line_break_holder] –><option value=”5″>5</option><!– [et_pb_line_break_holder] –><option value=”6″>6</option><!– [et_pb_line_break_holder] –><option value=”7″>7</option><!– [et_pb_line_break_holder] –><option value=”8″>8</option><!– [et_pb_line_break_holder] –><option value=”9″>9</option><!– [et_pb_line_break_holder] –><option value=”10″>10</option><!– [et_pb_line_break_holder] –><option value=”11″>11</option><!– [et_pb_line_break_holder] –><option value=”12″>12</option><!– [et_pb_line_break_holder] –><option value=”13″>13</option><!– [et_pb_line_break_holder] –><option value=”14″>14</option><!– [et_pb_line_break_holder] –><option value=”15″>15</option><!– [et_pb_line_break_holder] –><option value=”16″>16</option><!– [et_pb_line_break_holder] –><option value=”17″>17</option><!– [et_pb_line_break_holder] –><option value=”18″>18</option><!– [et_pb_line_break_holder] –><option value=”19″>19</option><!– [et_pb_line_break_holder] –><option value=”20″>20</option><!– [et_pb_line_break_holder] –><option value=”21″>21</option><!– [et_pb_line_break_holder] –><option value=”22″>22</option><!– [et_pb_line_break_holder] –><option value=”23″>23</option><!– [et_pb_line_break_holder] –><option value=”24″>24</option><!– [et_pb_line_break_holder] –><option value=”25″>25</option><!– [et_pb_line_break_holder] –><option value=”26″>26</option><!– [et_pb_line_break_holder] –><option value=”27″>27</option><!– [et_pb_line_break_holder] –><option value=”28″>28</option><!– [et_pb_line_break_holder] –><option value=”29″>29</option><!– [et_pb_line_break_holder] –><option value=”30″>30</option><!– [et_pb_line_break_holder] –><option value=”31″>31</option><!– [et_pb_line_break_holder] –></select><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><select id=”DateOfBirthYear” name=”DateOfBirthYear”><option value=””>Year</option><!– [et_pb_line_break_holder] –><option value=”2000″>2000</option><!– [et_pb_line_break_holder] –><option value=”1999″>1999</option><!– [et_pb_line_break_holder] –><option value=”1998″>1998</option><!– [et_pb_line_break_holder] –><option value=”1997″>1997</option><!– [et_pb_line_break_holder] –><option value=”1996″>1996</option><!– [et_pb_line_break_holder] –><option value=”1995″>1995</option><!– [et_pb_line_break_holder] –><option value=”1994″>1994</option><!– [et_pb_line_break_holder] –><option value=”1993″>1993</option><!– [et_pb_line_break_holder] –><option value=”1992″>1992</option><!– [et_pb_line_break_holder] –><option value=”1991″>1991</option><!– [et_pb_line_break_holder] –><option value=”1990″>1990</option><!– [et_pb_line_break_holder] –><option value=”1989″>1989</option><!– [et_pb_line_break_holder] –><option value=”1988″>1988</option><!– [et_pb_line_break_holder] –><option value=”1987″>1987</option><!– [et_pb_line_break_holder] –><option value=”1986″>1986</option><!– [et_pb_line_break_holder] –><option value=”1985″>1985</option><!– [et_pb_line_break_holder] –><option value=”1984″>1984</option><!– [et_pb_line_break_holder] –><option value=”1983″>1983</option><!– [et_pb_line_break_holder] –><option value=”1982″>1982</option><!– [et_pb_line_break_holder] –><option value=”1981″>1981</option><!– [et_pb_line_break_holder] –><option value=”1980″>1980</option><!– [et_pb_line_break_holder] –><option value=”1979″>1979</option><!– [et_pb_line_break_holder] –><option value=”1978″>1978</option><!– [et_pb_line_break_holder] –><option value=”1977″>1977</option><!– [et_pb_line_break_holder] –><option value=”1976″>1976</option><!– [et_pb_line_break_holder] –><option value=”1975″>1975</option><!– [et_pb_line_break_holder] –><option value=”1974″>1974</option><!– [et_pb_line_break_holder] –><option value=”1973″>1973</option><!– [et_pb_line_break_holder] –><option value=”1972″>1972</option><!– [et_pb_line_break_holder] –><option value=”1971″>1971</option><!– [et_pb_line_break_holder] –><option value=”1970″>1970</option><!– [et_pb_line_break_holder] –><option value=”1969″>1969</option><!– [et_pb_line_break_holder] –><option value=”1968″>1968</option><!– [et_pb_line_break_holder] –><option value=”1967″>1967</option><!– [et_pb_line_break_holder] –><option value=”1966″>1966</option><!– [et_pb_line_break_holder] –><option value=”1965″>1965</option><!– [et_pb_line_break_holder] –><option value=”1964″>1964</option><!– [et_pb_line_break_holder] –><option value=”1963″>1963</option><!– [et_pb_line_break_holder] –><option value=”1962″>1962</option><!– [et_pb_line_break_holder] –><option value=”1961″>1961</option><!– [et_pb_line_break_holder] –><option value=”1960″>1960</option><!– [et_pb_line_break_holder] –><option value=”1959″>1959</option><!– [et_pb_line_break_holder] –><option value=”1958″>1958</option><!– [et_pb_line_break_holder] –><option value=”1957″>1957</option><!– [et_pb_line_break_holder] –><option value=”1956″>1956</option><!– [et_pb_line_break_holder] –><option value=”1955″>1955</option><!– [et_pb_line_break_holder] –><option value=”1954″>1954</option><!– [et_pb_line_break_holder] –><option value=”1953″>1953</option><!– [et_pb_line_break_holder] –><option value=”1952″>1952</option><!– [et_pb_line_break_holder] –><option value=”1951″>1951</option><!– [et_pb_line_break_holder] –><option value=”1950″>1950</option><!– [et_pb_line_break_holder] –><option value=”1949″>1949</option><!– [et_pb_line_break_holder] –><option value=”1948″>1948</option><!– [et_pb_line_break_holder] –><option value=”1947″>1947</option><!– [et_pb_line_break_holder] –><option value=”1946″>1946</option><!– [et_pb_line_break_holder] –><option value=”1945″>1945</option><!– [et_pb_line_break_holder] –><option value=”1944″>1944</option><!– [et_pb_line_break_holder] –><option value=”1943″>1943</option><!– [et_pb_line_break_holder] –><option value=”1942″>1942</option><!– [et_pb_line_break_holder] –><option value=”1941″>1941</option><!– [et_pb_line_break_holder] –><option value=”1940″>1940</option><!– [et_pb_line_break_holder] –><option value=”1939″>1939</option><!– [et_pb_line_break_holder] –><option value=”1938″>1938</option><!– [et_pb_line_break_holder] –><option value=”1937″>1937</option><!– [et_pb_line_break_holder] –><option value=”1936″>1936</option><!– [et_pb_line_break_holder] –><option value=”1935″>1935</option><!– [et_pb_line_break_holder] –><option value=”1934″>1934</option><!– [et_pb_line_break_holder] –><option value=”1933″>1933</option><!– [et_pb_line_break_holder] –><option value=”1932″>1932</option><!– [et_pb_line_break_holder] –><option value=”1931″>1931</option><!– [et_pb_line_break_holder] –><option value=”1930″>1930</option><!– [et_pb_line_break_holder] –><option value=”1929″>1929</option><!– [et_pb_line_break_holder] –><option value=”1928″>1928</option><!– [et_pb_line_break_holder] –><option value=”1927″>1927</option><!– [et_pb_line_break_holder] –><option value=”1926″>1926</option><!– [et_pb_line_break_holder] –><option value=”1925″>1925</option><!– [et_pb_line_break_holder] –><option value=”1924″>1924</option><!– [et_pb_line_break_holder] –><option value=”1923″>1923</option><!– [et_pb_line_break_holder] –><option value=”1922″>1922</option><!– [et_pb_line_break_holder] –><option value=”1921″>1921</option><!– [et_pb_line_break_holder] –><option value=”1920″>1920</option><!– [et_pb_line_break_holder] –><option value=”1919″>1919</option><!– [et_pb_line_break_holder] –><option value=”1918″>1918</option><!– [et_pb_line_break_holder] –><option value=”1917″>1917</option><!– [et_pb_line_break_holder] –></select><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”form-group”><!– [et_pb_line_break_holder] –><label for=”landing-facility”>Zip Code</label><!– [et_pb_line_break_holder] –><input type=”text” class=”form-control” id=”landing-facility” name=”landing-facility” required=””><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –><div class=”text-center”><!– [et_pb_line_break_holder] –><button type=”submit” class=”btn btn-default landing-form-btn” name=”landingSubmit”>Submit</button><!– [et_pb_line_break_holder] –></div><!– [et_pb_line_break_holder] –></form>[/et_pb_code][/et_pb_column][/et_pb_row][/et_pb_section]