29 |
> |
> |
30 |
<table width="90%" border="0" cellspacing="3" cellpadding="0" align="center"> |
<table width="90%" border="0" cellspacing="3" cellpadding="0" align="center"> |
31 |
<tr> |
<tr> |
32 |
<td><b>First Name</b>: </td> |
<td>{rinput name=first_name desc="First Name:"}</td> |
33 |
<td> |
<td> |
34 |
<input type="text" name="first_name" size="30"> |
{input type="text" name="first_name" size="30"} |
35 |
</td> |
</td> |
36 |
</tr> |
</tr> |
37 |
<tr> |
<tr> |
38 |
<td> <b>Last Name: </b></td> |
<td>{rinput name=last_name desc="Last Name:"}</b></td> |
39 |
<td> |
<td> |
40 |
<input type="text" name="last_name" size="30"> |
{input type="text" name="last_name" size="30"} |
41 |
</td> |
</td> |
42 |
</tr> |
</tr> |
43 |
<tr> |
<tr> |
44 |
<td><b>Address Line 1: </b></td> |
<td>{rinput name=address1 desc="Address Line 1:"}</td> |
45 |
<td> |
<td> |
46 |
<input type="text" name="address1" size="30"> |
{input type="text" name="address1" size="30"} |
47 |
</td> |
</td> |
48 |
</tr> |
</tr> |
49 |
<tr> |
<tr> |
50 |
<td><b>Address Line 2:</b></td> |
<td>Address Line 2:</td> |
51 |
<td> |
<td> |
52 |
<input type="text" name="address2" size="30"> |
<input type="text" name="address2" size="30"> |
53 |
</td> |
</td> |
54 |
</tr> |
</tr> |
55 |
<tr> |
<tr> |
56 |
<td><b>City:</b></td> |
<td>{rinput name=city desc="City:"}</td> |
57 |
<td> |
<td> |
58 |
<input type="text" name="city" size="30"> |
{input type="text" name="city" size="30"} |
59 |
</td> |
</td> |
60 |
</tr> |
</tr> |
61 |
<tr> |
<tr> |
62 |
<td><b>State/Province:</b></td> |
<td>State/Province:</td> |
63 |
<td> |
<td> |
64 |
<input type="text" name="state" size="30"> |
<input type="text" name="state" size="30"> |
65 |
</td> |
</td> |
66 |
</tr> |
</tr> |
67 |
<tr> |
<tr> |
68 |
<td><b>ZIP/Postal Code: </b></td> |
<td>{rinput name=zip desc="ZIP/Postal Code:"}</td> |
69 |
<td> |
<td> |
70 |
<input type="text" name="zip" size="30"> |
{input type="text" name="zip" size="30"} |
71 |
</td> |
</td> |
72 |
</tr> |
</tr> |
73 |
<tr> |
<tr> |
82 |
</td> |
</td> |
83 |
</tr> |
</tr> |
84 |
<tr> |
<tr> |
85 |
<td><b>Email Address: </b> </td> |
<td>{rinput name=email desc="Email Address:"}</td> |
86 |
<td> |
<td> |
87 |
<input type="text" name="email" size="30"> |
{input type="email" name="email" size="30"} |
88 |
</td> |
</td> |
89 |
</tr> |
</tr> |
90 |
<tr> |
<tr> |
91 |
<td><b>Telephone:</b> |
<td>{rinput name=tel desc="Telephone:"}</td> |
|
</td> |
|
92 |
<td> |
<td> |
93 |
<input type="text" name="tel" size="30"> |
{input type="text" name="tel" size="30"} |
94 |
</td> |
</td> |
95 |
</tr> |
</tr> |
96 |
<tr> |
<tr> |
138 |
</tr> |
</tr> |
139 |
<tr> |
<tr> |
140 |
<td colspan="2" valign="top"> |
<td colspan="2" valign="top"> |
141 |
<div align="left"><b>Comments:</b> |
<div align="left">Comments: |
142 |
<br> |
<br> |
143 |
<textarea name="comments" rows=5 cols=40></textarea> |
<textarea name="comments" rows=5 cols=40></textarea> |
144 |
</div> |
</div> |