<CENTER><P>
|
<FORM
action="http://www.bravenet.co
m/emailfwd/senddata.asp"
method="post">
|
<INPUT type="hidden"
name="usernum"
value="1033780865">
|
<TABLE border="1"
cellpadding="10"
bgcolor="cornsilk"><TR><TD>
|
What is your name?<BR>
|
<INPUT type="text"
name="name" size="20"><BR>
|
Where are you from?<BR>
|
<INPUT type="text"
name="where" size="20"><BR>
|
E-mail address?<BR>
|
<INPUT type="text"
name="replyemail"
size="20"><BR>
|
<BR><CENTER>
|
<INPUT type="submit"
name="submit" value=" Send ">
|
<INPUT type="reset"
name="reset" value=" Clear
"><HR>
|
<A
href="http://www.bravenet.com/"
>
|
<IMG
src="http://images.bravenet.com/
brpics/formbutt.gif"
border="0"></A>
|
</TD></TR></TABLE>
|
</FORM></CENTER
|