<?xml version="1.0" encoding="iso-8859-1"?><!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"><html xmlns="http://www.w3.org/1999/xhtml"><head> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" /> <title></title> <style type="text/css" media="print"> .fillout { color: black; border-width: 0; border-bottom: 1px solid #000; width: 300pt; .postselect { display: block; width: 300pt; height: 1em; border: none; border-bottom: 1px solid #000; } </style></head><body><form><h2>Order Form</h2> <table cellspacing="0"> <tr> <td width="116"><label for="fname">First Name<label>:</td> <td><input class="fillout" name="fname" type="text" id="fname" /></td> </tr> <tr> <td>Last Name:</td> <td><input class="fillout" name="lname" type="text" id="lname" /></td> </tr> <tr> <td>Email:</td> <td><input class="fillout" name="email" type="text" id="email" /></td> </tr> <tr> <td>Address:</td> <td><input class="fillout" name="address1" type="text" id="address1" /> </td> </tr> <tr> <td> </td> <td><input class="fillout" name="address2" type="text" id="address2" /></td> </tr> <tr> <td>City:</td> <td><input class="fillout" name="city" type="text" id="city" /></td> </tr> <tr> <td>State/Province:</td> <td> <select name="state" size="1"> <option selected="selected">Select</option> <option>Alabama </option> <option>Alaska </option> <option>Arizona </option> <option>Arkansas </option> <option>California </option> <option>Colorado </option> <option>Connecticut </option> <option>Delaware </option> <option>Florida </option> <option>Georgia </option> <option>Hawaii </option> <option>Idaho </option> <option>Illinois </option> <option>Indiana </option> <option>Iowa </option> <option>Kansas </option> <option>Kentucky </option> <option>Louisiana </option> <option>Maine </option> <option>Maryland </option> <option>Massachusetts </option> <option>Michigan </option> <option>Minnesota </option> <option>Mississippi </option> <option>Missouri </option> <option>Montana </option> <option>Nebraska </option> <option>Nevada </option> <option>New Hampshire </option> <option>New Jersey </option> <option>New Mexico </option> <option>New York </option> <option>North Carolina </option> <option>North Dakota </option> <option>Ohio </option> <option>Oklahoma </option> <option>Oregon </option> <option>Pennsylvania </option> <option>Rhode Island </option> <option>South Carolina </option> <option>South Dakota </option> <option>Tennessee </option> <option>Texas </option> <option>Utah </option> <option>Vermont </option> <option>Virginia </option> <option>Washington </option> <option>Washington, D.C. </option> <option>West Virginia </option> <option>Wisconsin </option> <option>Wyoming </option> <option>---------- </option> <option>Alberta </option> <option>British Columbia </option> <option>Manitoba </option> <option>New Brunswick </option> <option>New Foundland </option> <option>Nova Scotia </option> <option>Northwest Territories </option> <option>Ontario </option> <option>Prince Edward Island </option> <option>Quebec </option> <option>Saskatchewan </option> <option>Yukon Territory </option> <option>Other </option> </select><span class="postselect"> </span> </td> </tr> <tr> <td>Zip Code:</td> <td><input class="fillout" name="zip" type="text" id="zip" /></td> </tr> <tr> <td>Daytime Phone:</td> <td><input class="fillout" name="dayphone" type="text" id="dayphone" /></td> </tr> <tr> <td>Product(s):</td> <td><input name="product" type="checkbox" id="product" value="ezweb" />Web ($19.95) <input name="product" type="checkbox" id="product" value="ezwebultra" />Ping ($29.95)</td> </tr> <tr> <td>Type of Credit Card:</td> <td><input type="radio" name="cc" value="mastercard" /> Mastercard <input type="radio" name="cc" value="visa" /> Visa <input type="radio" name="cc" value="discover" /> Discover</td> </tr> <tr> <td>Name on Credit Card:</td> <td><input class="fillout" name="ccname" type="text" id="ccname" /></td> </tr> <tr> <td>Card Number:</td> <td><input class="fillout" name="ccnumber" type="text" id="ccnumber" /></td> </tr> <tr> <td>Card Expiration Date:</td> <td><input class="fillout" name="ccnumber" type="text" id="ccnumber" /></td> </tr> </table><input type="submit" name="Submit" value="Submit" id="submit" /></form></body></html>