  <div>
    <h1>Dialer</h1>

    <form id="appform" method="post" name="appform">
      <div id="city_div">
        City: <input type="text" name="city">
      </div>

      <div id="state_div">
        State: <input type="text" name="state">
      </div>

      <div id="company_div">
        Company: <input type="text" name="company">
      </div>

      <div id="data_source_div">
        Data Source: <input type="text" name="data_source">
      </div><input type="submit" value="locate records">
    </form>
  </div>
