enrollment form 2

<form name="contactForm" method="post" action="http://www.mycontactform.com/sendform/sendform.php">
<input name="user" type="hidden" id="user" value="jowaje"><input name="formid" type="hidden" id="formid" value="79032">
<table width="100%" border="0" cellpadding="0" cellspacing="0" bordercolor="#000000" bgcolor="#FFFFFF"><tr><td>
<table width="100%" border="0" cellspacing="0" cellpadding="2">
<tr><td><font color="#000000" size="2" face="Arial"><b> Subject:<font color="#FF0000"> *</font></b></font></td><td><select name="subject" id="subject" class="fieldstyle"><option value="Jowaje Health Advice Service">Jowaje Health Advice Service</option><option value="Jowaje Newsletters">Jowaje Newsletters</option><option value="Both">Both</option></select></td></tr><tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>First Name<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[1]" type="text" id="q[1]" value="" size="15" maxlength="" class="fieldstyle"></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>Last Name<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[2]" type="text" id="q[2]" value="" size="15" maxlength="" class="fieldstyle"></font></td></tr>
<tr><td><font color="#000000" size="2" face="Arial"><b> E-mail Address:<font color="#FF0000"> *</font></b></font></td><td><input name="email" type="text" id="email" size="20" maxlength="100" class="fieldstyle"></td></tr><tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>Age<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[3]" type="text" id="q[3]" value="" size="2" maxlength="2" class="fieldstyle"></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>Address<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><textarea name="q[4]" cols="30" rows="2" class="fieldstyle"></textarea></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>City<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[5]" type="text" id="q[5]" value="" size="15" maxlength="" class="fieldstyle"></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>State<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[6]" type="text" id="q[6]" value="" size="30" maxlength="" class="fieldstyle"></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>Phone<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[7]" type="text" id="q[7]" value="" size="11" maxlength="11" class="fieldstyle"></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>How did you hear about Jowaje?</b></font></td><td><font color="#000000" size="2" face="Arial"><textarea name="q[8]" cols="50" rows="3" class="fieldstyle"></textarea></font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>Would you refer this site to a friend?</b></font></td><td><font color="#000000" size="2" face="Arial"><input type="radio" name="q[9]" value="Yes" class="fieldstyle">Yes<br><input type="radio" name="q[9]" value="No" class="fieldstyle">No<br><input type="radio" name="q[9]" value="Maybe" class="fieldstyle">Maybe</font></td></tr>
<tr bgcolor=""><td><font color="#000000" size="2" face="Arial"><b>You have read and agree with disclaimer?<font color="#FF0000"> *</font></b></font></td><td><font color="#000000" size="2" face="Arial"><input name="q[10]" type="checkbox" id="q[10]" value="Dont Leave Blank" ></font></td></tr>
<tr><td colspan="2"><hr size="1"></td></tr>
<tr><td colspan="2"><input name="submit" type="submit" value="Submit"> <input name="reset" type="reset" value="Reset"> <input type="button" value="Print" onClick="window.print()"> </td></tr>
<tr><td><font color="#FF0000" size="1" face="Verdana, Arial, Helvetica, sans-serif"><b>*</b></font> <font size="1" face="Verdana, Arial, Helvetica, sans-serif">Required</font></td><td align="right"><font size="1" face="Verdana, Arial, Helvetica, sans-serif"><a href="http://www.mycontactform.com">Powered by <strong>myContactForm.com</strong></a></font></td></tr>
</table></td></tr></table></form>

Jowaje Publishing

The First No-nonsense approach to getting the best health care possible!