{jumi}
<form action="s.php" method="post">
<input type="hidden" name="r" value="1">
<input type="hidden" name="h" value="1">
<input type="hidden" name="a" value="sub">
<input type="hidden" name="ref" value="none">
<table width="365" border="0" cellspacing="6" cellpadding="0" style="border: 1px solid #000000;">
<tr>
<td colspan="2" bgcolor="#3399ff">
<font color="#eae4fc face="Tahoma, Arial, Helvetica, sans-serif">
<strong>Your Information:</strong>
</font>
</td>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
Your Name (First, Last)
</font>
</strong>
<br>
<input type="text" name="f" size=20 maxlength=60>
<input type="text" name="l" size=23 maxlength=60>
</td>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
City:
</font>
</strong>
<br>
<input maxlength="95" size="45" name="cf_city">
</td>
</tr>
<tr>
<td>
<strong>
<font color="#003366" face="arial" size="2">
State:
</font>
</strong>
<br>
<select name="cf_state">
<option value="al">AL</option>
<option value="ak">AK</option>
<option value="az">AZ</option>
<option value="ar">AR</option>
<option value="ca">CA</option>
<option value="co">CO</option>
<option value="ct">CT</option>
<option value="de">DE</option>
<option value="dc">DC</option>
<option value="fl">FL</option>
<option value="ga">GA</option>
<option value="hi">HI</option>
<option value="id">ID</option>
<option value="il">IL</option>
<option value="in">IN</option>
<option value="ia">IA</option>
<option value="ks">KS</option>
<option value="ky">KY</option>
<option value="la">LA</option>
<option value="me">ME</option>
<option value="md">MD</option>
<option value="ma">MA</option>
<option value="mi">MI</option>
<option value="mn">MN</option>
<option value="ms">MS</option>
<option value="mo">MO</option>
<option value="mt">MT</option>
<option value="ne">NE</option>
<option value="nv">NV</option>
<option value="nh">NH</option>
<option value="nj">NJ</option>
<option value="nm">NM</option>
<option value="ny">NY</option>
<option value="nc">NC</option>
<option value="nd">ND</option>
<option value="oh">OH</option>
<option value="ok">OK</option>
<option value="or">OR</option>
<option value="pa">PA</option>
<option value="ri">RI</option>
<option value="sc">SC</option>
<option value="sd">SD</option>
<option value="tn">TN</option>
<option value="tx">TX</option>
<option value="ut">UT</option>
<option value="vt">VT</option>
<option value="va">VA</option>
<option value="wa">WA</option>
<option value="wi">WI</option>
<option value="wv">WV</option>
<option value="wy">WY</option>
</select>
</td>
<td>
<strong>
<font color="#003366" face="arial" size="2">
Zipcode:
</font>
</strong>
<br>
<input maxlength="14" size="15" name="cf_zipcode"> </font></td>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
Daytime Phone: (ie: 999-555-1234):
</font>
</strong>
<br>
<input maxlength="20" size="15" name="cf_homephone"> -
</td>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
What features interest you?
</font>
</strong>
<br>
<select name="cf_interest">
<option value="I need an Internet eCommerce Solution
<option value="Upgrade my old web site
<option value="Help me build a web site
<option value="Help with a new web site
<option value="Other
</select>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
Skyp ID (opt):
</font>
</strong>
<br>
<input maxlength="99" size="45" name="cf_SkypeID">
</td>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
Email Address
</font>
<font color="#003366" size="1" face="arial">
(Required for Confirmation)
</font>
</strong>
<br>
<input type="text" name="e" size=45 maxlength=50><br>
</td>
</tr>
<tr>
<td colspan="2">
<strong>
<font color="#003366" face="arial" size="2">
Best Time To Contact You?
</font>
</strong>
<br>
<select name="cf_best_contact_time">
<option value="Early morning (before 8am)">Early morning (before 8am)
<option value="Morning (8am to 11am)">Morning (8am to 11am)
<option value="Noon (11am to 1pm)">Noon (11am to 1pm)
<option value="Afternoon (1pm to 3pm)" SELECTED>Afternoon (1pm to 3pm)
<option value="Late afternoon (3pm to 6pm)">Late afternoon (3pm to 6pm)
<option value="Evening (6pm to 8pm)">Evening (6pm to 8pm)
<option value="Night-time (8pm to 10pm)">Night-time (8pm to 10pm)
<option value="Late night (10pm to midnight)">Late night (10pm to midnight)
</select>
</tr>
</table>
<font color="#003366" face="Tahoma, Arial, Helvetica, sans-serif" size="1">
I want to receive additional free offers.
</font>
<input checked="checked" type="checkbox" name="cf_other_offers" value="1">
<input id="submit" type="submit" value="Submit">
</form>
{/jumi}
