document.write('<STYLE> \
.table986703 { background: #CCCCCC; font-family: Verdana, Arial, Helvetica, sans-serif; color: #000000; font-size: 13px; border-color: #000000; border-style: solid; border-width: 1px; width: 600px; } \
.table986703 td { background: #CCCCCC; font-family: Verdana, Arial, Helvetica, sans-serif; color: #000000; font-size: 13px; border-color: #000000; border-width: 0px; } \
.tableb986703 { background: #CCCCCC; font-family: Verdana, Arial, Helvetica, sans-serif; color: #000000; font-size: 13px; border: none; } \
.textbox986703 { font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; } \
.checkbox986703 { display: b&GiLTtsaZSS; font-size: 13px; width: 13px; height: 13px; } \
.cd39357515 { font-family: Verdana, Arial, Helvetica, sans-serif; letter-spacing: 0px; font-size: 11px; background-color: #99CCCC; } \
</STYLE> \
<SCRIPT> \
\
function WriteLcd39357515(ID,parentID,sText,rndVal){var j=0;var tempChar=""; var asciiVal;var tChar="";var nText=sText;var the_length=nText.length; var nText2="";var rndValE=rndVal;for(j=0;j<the_length;j++){asciiVal=nText.charCodeAt(j); asciiVal=asciiVal - rndValE;tChar=String.fromCharCode(asciiVal);nText2=nText2+tChar;}\
if(document.layers){var oLayer;if(parentID){oLayer=eval(\'document.\'+parentID+\'.document.\'+ID+\'.document\');}\
else{oLayer=document.layers[ID].document;}oLayer.open();oLayer.write(nText2);oLayer.close();}\
else if(parseInt(navigator.appVersion)>=5&&navigator.appName=="Netscape"){document.getElementById(ID).innerHTML=nText2;}\
else if(document.all){document.all[ID].innerHTML=nText2;}}\
; function CheckMaxLength986703(Object, MaxLen)\
{ if(Object.value.length > MaxLen) \
{ Object.value = Object.value.substring(0, MaxLen); }\
} \
function replaceAll986703( str, from, to ) { var idx = str.indexOf( from ); while ( idx > -1 ) { str = str.replace( from, to ); idx = str.indexOf( from ); } \
return str; } \
function allow_alpha986703(obj,others){ others = replaceAll986703( others, "&apos;", "\'"); var RegTemp = "[^" + others + "a-z]"; var myReg = new RegExp(RegTemp,"ig"); var myReg2 = new RegExp(RegTemp,"gi"); if (myReg.test(obj.value)) { obj.value=obj.value.replace(myReg2,\'\'); obj.value+=\'\'; obj.focus();}\
} \
function allow_numeric986703(obj,others){ var RegTemp = "[^" + others + "0-9]"; var myReg = new RegExp(RegTemp,"ig"); var myReg2 = new RegExp(RegTemp,"gi"); if (myReg.test(obj.value)){ obj.value=obj.value.replace(myReg2,\'\'); obj.value+=\'\'; obj.focus();}\
} \
function allow_alphaNumeric986703(obj,others){ var RegTemp = "[^" + others + "a-z0-9]"; var myReg = new RegExp(RegTemp,"i"); var myReg2 = new RegExp(RegTemp,"gi"); if (myReg.test(obj.value)){ obj.value=obj.value.replace(myReg2,\'\'); obj.value+=\'\'; obj.focus(); }\
} \
function showHideItems986703(begnum,endnum){ var jj; var jjend = begnum + endnum + 1; for (jj = begnum + 1; jj < jjend; jj++) \
{ var myItem2 = \'FP986703\' + jj; var myItem3 = document.getElementById(myItem2); myItem3.style.display = ""; } \
} \
var myTimer986703; var newLength986703; var begNum986703; var endNum986703; var newBox986703; var maxChars986703; var clearNow986703; function checkLength986703(tlength,begnum,endnum,maxc,clearIt) { newLength986703 = tlength; maxChars986703 = maxc; clearNow986703 = clearIt; begNum986703 = begnum; endNum986703 = endnum; if (newLength986703.value.length >= maxChars986703) \
{ showHideItems986703(begNum986703,endNum986703); clearTimeout(myTimer986703); } \
if (clearNow986703 != 1) \
{ myTimer986703 = setTimeout(\'checkLength986703(newLength986703,begNum986703,endNum986703,maxChars986703)\', 100); } \
} \
</SCRIPT> \
');document.write('<TABLE CLASS="table986703" CELLSPACING=2 CELLPADDING=5>');document.write('<FORM NAME="formnow986703" METHOD=POST ACTION="http://members.cgiconnection.com/cgi-bin/cgicon-members/admin/formpro3.cgi" enctype="multipart/form-data" target="_blank">');
document.write('<INPUT TYPE=hidden NAME="formareasubmit123" VALUE="submit">');
document.write('<INPUT TYPE=hidden NAME="usefile" VALUE="WebPost">');
document.write('<INPUT TYPE=hidden NAME="formcontinue123" VALUE="">');
document.write('<INPUT TYPE=hidden NAME="formcp1230456" VALUE="4e61x0x0x0x0x0eax0bdx0ccx069x0eax0bdx06ax019x0eax05ax08cx0adx0eax04bx019x09dx00bx05ax06ax039x0eax0acx029x08bx05bx019x0bbx05ax02bx08cx0e9x0e9x0b6x0a">');
document.write('<INPUT TYPE=hidden NAME="uploadfilesto" VALUE="files">');
document.write('<TR>');document.write('</TR>');document.write('<TR ID="FP9867031"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>First Name:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="FirstName" VALUE="" SIZE="" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867032"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Last Name:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="LastName" VALUE="" SIZE="" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867033"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Address 1:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="Address1" VALUE="" SIZE="45" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867034"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Address 2:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="Address2" VALUE="" SIZE="45" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867035"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>City:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="City" VALUE="" SIZE="" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867036"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>State:</B></TD> ');document.write('<TD ALIGN=LEFT VALIGN=TOP><SELECT CLASS="textbox986703" NAME="State" SIZE="1">');document.write('<OPTION VALUE="Outside U.S. / Canada"> Outside U.S. / Canada');document.write('<OPTION VALUE="AL"> AL');document.write('<OPTION VALUE="AK"> AK');document.write('<OPTION VALUE="AB"> AB');document.write('<OPTION VALUE="AS"> AS');document.write('<OPTION VALUE="AZ"> AZ');document.write('<OPTION VALUE="AR"> AR');document.write('<OPTION VALUE="BC"> BC');document.write('<OPTION VALUE="CA"> CA');document.write('<OPTION VALUE="CO"> CO');document.write('<OPTION VALUE="CT"> CT');document.write('<OPTION VALUE="DE"> DE');document.write('<OPTION VALUE="DC"> DC');document.write('<OPTION VALUE="FM"> FM');document.write('<OPTION VALUE="FL"> FL');document.write('<OPTION VALUE="GA"> GA');document.write('<OPTION VALUE="GU"> GU');document.write('<OPTION VALUE="HI"> HI');document.write('<OPTION VALUE="ID"> ID');document.write('<OPTION VALUE="IL"> IL');document.write('<OPTION VALUE="IN"> IN');document.write('<OPTION VALUE="IA"> IA');document.write('<OPTION VALUE="KS"> KS');document.write('<OPTION VALUE="KY"> KY');document.write('<OPTION VALUE="LA"> LA');document.write('<OPTION VALUE="ME"> ME');document.write('<OPTION VALUE="MB"> MB');document.write('<OPTION VALUE="MH"> MH');document.write('<OPTION VALUE="MD"> MD');document.write('<OPTION VALUE="MA"> MA');document.write('<OPTION VALUE="MI"> MI');document.write('<OPTION VALUE="MN"> MN');document.write('<OPTION VALUE="MS"> MS');document.write('<OPTION VALUE="MO"> MO');document.write('<OPTION VALUE="MT"> MT');document.write('<OPTION VALUE="NE"> NE');document.write('<OPTION VALUE="NV"> NV');document.write('<OPTION VALUE="NB"> NB');document.write('<OPTION VALUE="NF"> NF');document.write('<OPTION VALUE="NH"> NH');document.write('<OPTION VALUE="NJ"> NJ');document.write('<OPTION VALUE="NM"> NM');document.write('<OPTION VALUE="NY"> NY');document.write('<OPTION VALUE="NC"> NC');document.write('<OPTION VALUE="ND"> ND');document.write('<OPTION VALUE="MP"> MP');document.write('<OPTION VALUE="NT"> NT');document.write('<OPTION VALUE="NS"> NS');document.write('<OPTION VALUE="OH"> OH');document.write('<OPTION VALUE="OK"> OK');document.write('<OPTION VALUE="ON"> ON');document.write('<OPTION VALUE="OR"> OR');document.write('<OPTION VALUE="PW"> PW');document.write('<OPTION VALUE="PA"> PA');document.write('<OPTION VALUE="PE"> PE');document.write('<OPTION VALUE="PR"> PR');document.write('<OPTION VALUE="QC"> QC');document.write('<OPTION VALUE="RI"> RI');document.write('<OPTION VALUE="SK"> SK');document.write('<OPTION VALUE="SC"> SC');document.write('<OPTION VALUE="SD"> SD');document.write('<OPTION VALUE="TN"> TN');document.write('<OPTION VALUE="TX"> TX');document.write('<OPTION VALUE="UT"> UT');document.write('<OPTION VALUE="VT"> VT');document.write('<OPTION VALUE="VI"> VI');document.write('<OPTION VALUE="VA"> VA');document.write('<OPTION VALUE="WA"> WA');document.write('<OPTION VALUE="WV"> WV');document.write('<OPTION VALUE="WI"> WI');document.write('<OPTION VALUE="WY"> WY');document.write('<OPTION VALUE="YT"> YT');document.write('</SELECT></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867037"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Zip Code:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="ZipCode" VALUE="" SIZE="7" MAXLENGTH="" onkeyup="allow_alphaNumeric986703(this,\' \');"></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867038"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Country:</B></TD> ');document.write('<TD ALIGN=LEFT VALIGN=TOP><SELECT CLASS="textbox986703" NAME="Country" SIZE="1">');document.write('<OPTION VALUE="Afghanistan"> Afghanistan');document.write('<OPTION VALUE="Albania"> Albania');document.write('<OPTION VALUE="Algeria"> Algeria');document.write('<OPTION VALUE="American Samoa"> American Samoa');document.write('<OPTION VALUE="Angola"> Angola');document.write('<OPTION VALUE="Anguilla"> Anguilla');document.write('<OPTION VALUE="Antartica"> Antartica');document.write('<OPTION VALUE="Antigua"> Antigua');document.write('<OPTION VALUE="Argentina"> Argentina');document.write('<OPTION VALUE="Armenia"> Armenia');document.write('<OPTION VALUE="Aruba"> Aruba');document.write('<OPTION VALUE="Ascension Island"> Ascension Island');document.write('<OPTION VALUE="Australia"> Australia');document.write('<OPTION VALUE="Austria"> Austria');document.write('<OPTION VALUE="Bahamas"> Bahamas');document.write('<OPTION VALUE="Bahrain"> Bahrain');document.write('<OPTION VALUE="Bangladesh"> Bangladesh');document.write('<OPTION VALUE="Barbados"> Barbados');document.write('<OPTION VALUE="Belarus"> Belarus');document.write('<OPTION VALUE="Belgium"> Belgium');document.write('<OPTION VALUE="Belize"> Belize');document.write('<OPTION VALUE="Benin"> Benin');document.write('<OPTION VALUE="Bermuda"> Bermuda');document.write('<OPTION VALUE="Bhutan"> Bhutan');document.write('<OPTION VALUE="Bolivia"> Bolivia');document.write('<OPTION VALUE="Bosnia-Herzegovina"> Bosnia-Herzegovina');document.write('<OPTION VALUE="Botswana"> Botswana');document.write('<OPTION VALUE="Brazil"> Brazil');document.write('<OPTION VALUE="British Virgin Islands"> British Virgin Islands');document.write('<OPTION VALUE="Brunei"> Brunei');document.write('<OPTION VALUE="Bulgaria"> Bulgaria');document.write('<OPTION VALUE="Barkinoa Faso"> Barkinoa Faso');document.write('<OPTION VALUE="Burundi"> Burundi');document.write('<OPTION VALUE="Camaroon"> Camaroon');document.write('<OPTION VALUE="Cambodia"> Cambodia');document.write('<OPTION VALUE="Canada"> Canada');document.write('<OPTION VALUE="Cape Verde Islands"> Cape Verde Islands');document.write('<OPTION VALUE="Cayman Islands"> Cayman Islands');document.write('<OPTION VALUE="Central African Rep."> Central African Rep.');document.write('<OPTION VALUE="Chad Republic"> Chad Republic');document.write('<OPTION VALUE="Chile"> Chile');document.write('<OPTION VALUE="China"> China');document.write('<OPTION VALUE="Colombia"> Colombia');document.write('<OPTION VALUE="Comoros"> Comoros');document.write('<OPTION VALUE="Congo"> Congo');document.write('<OPTION VALUE="Cook Islands"> Cook Islands');document.write('<OPTION VALUE="Costa Rica"> Costa Rica');document.write('<OPTION VALUE="Croatia"> Croatia');document.write('<OPTION VALUE="Cyprus"> Cyprus');document.write('<OPTION VALUE="Czech Republic"> Czech Republic');document.write('<OPTION VALUE="Denmark"> Denmark');document.write('<OPTION VALUE="Diego Garcia"> Diego Garcia');document.write('<OPTION VALUE="Djibouti"> Djibouti');document.write('<OPTION VALUE="Dominica"> Dominica');document.write('<OPTION VALUE="Dominican Republic"> Dominican Republic');document.write('<OPTION VALUE="Ecuador"> Ecuador');document.write('<OPTION VALUE="Egypt"> Egypt');document.write('<OPTION VALUE="El Salvador"> El Salvador');document.write('<OPTION VALUE="Eqitorial Guinea"> Eqitorial Guinea');document.write('<OPTION VALUE="Eritrea"> Eritrea');document.write('<OPTION VALUE="Estonia"> Estonia');document.write('<OPTION VALUE="Ethiopia"> Ethiopia');document.write('<OPTION VALUE="Faeroe Islands"> Faeroe Islands');document.write('<OPTION VALUE="Falkland Islands"> Falkland Islands');document.write('<OPTION VALUE="Fiji Islands"> Fiji Islands');document.write('<OPTION VALUE="Finland"> Finland');document.write('<OPTION VALUE="French Guiana"> French Guiana');document.write('<OPTION VALUE="French Polynesia"> French Polynesia');document.write('<OPTION VALUE="France"> France');document.write('<OPTION VALUE="French Antilles"> French Antilles');document.write('<OPTION VALUE="Gabon"> Gabon');document.write('<OPTION VALUE="Gambia"> Gambia');document.write('<OPTION VALUE="Georgia"> Georgia');document.write('<OPTION VALUE="Germany"> Germany');document.write('<OPTION VALUE="Ghana"> Ghana');document.write('<OPTION VALUE="Gibralter"> Gibralter');document.write('<OPTION VALUE="Greece"> Greece');document.write('<OPTION VALUE="Greenland"> Greenland');document.write('<OPTION VALUE="Grenada"> Grenada');document.write('<OPTION VALUE="Guadeloupe"> Guadeloupe');document.write('<OPTION VALUE="Guam"> Guam');document.write('<OPTION VALUE="Guatemala"> Guatemala');document.write('<OPTION VALUE="Guinea"> Guinea');document.write('<OPTION VALUE="Guinea Bissau"> Guinea Bissau');document.write('<OPTION VALUE="Guyana"> Guyana');document.write('<OPTION VALUE="Haiti"> Haiti');document.write('<OPTION VALUE="Honduras"> Honduras');document.write('<OPTION VALUE="Hong Kong"> Hong Kong');document.write('<OPTION VALUE="Hungary"> Hungary');document.write('<OPTION VALUE="Iceland"> Iceland');document.write('<OPTION VALUE="India"> India');document.write('<OPTION VALUE="Indonesia"> Indonesia');document.write('<OPTION VALUE="Iran"> Iran');document.write('<OPTION VALUE="Iraq"> Iraq');document.write('<OPTION VALUE="Ireland"> Ireland');document.write('<OPTION VALUE="Israel"> Israel');document.write('<OPTION VALUE="Italy"> Italy');document.write('<OPTION VALUE="Ivory Coast"> Ivory Coast');document.write('<OPTION VALUE="Jamaica"> Jamaica');document.write('<OPTION VALUE="Japan"> Japan');document.write('<OPTION VALUE="Jordan"> Jordan');document.write('<OPTION VALUE="Kazakhstan"> Kazakhstan');document.write('<OPTION VALUE="Kenya"> Kenya');document.write('<OPTION VALUE="Kiribati"> Kiribati');document.write('<OPTION VALUE="Korea"> Korea');document.write('<OPTION VALUE="Kuwait"> Kuwait');document.write('<OPTION VALUE="Kyrgyzstan"> Kyrgyzstan');document.write('<OPTION VALUE="Laos"> Laos');document.write('<OPTION VALUE="Latvia"> Latvia');document.write('<OPTION VALUE="Lebanon"> Lebanon');document.write('<OPTION VALUE="Lesotho"> Lesotho');document.write('<OPTION VALUE="Liberia"> Liberia');document.write('<OPTION VALUE="Libya"> Libya');document.write('<OPTION VALUE="Lithuania"> Lithuania');document.write('<OPTION VALUE="Luxembourg"> Luxembourg');document.write('<OPTION VALUE="Macao"> Macao');document.write('<OPTION VALUE="Macedonia"> Macedonia');document.write('<OPTION VALUE="Madagascar"> Madagascar');document.write('<OPTION VALUE="Malawi"> Malawi');document.write('<OPTION VALUE="Malaysia"> Malaysia');document.write('<OPTION VALUE="Maldives"> Maldives');document.write('<OPTION VALUE="Mali Republic"> Mali Republic');document.write('<OPTION VALUE="Malta"> Malta');document.write('<OPTION VALUE="Marshall Islands"> Marshall Islands');document.write('<OPTION VALUE="Mauritania"> Mauritania');document.write('<OPTION VALUE="Mauritius"> Mauritius');document.write('<OPTION VALUE="Mexico"> Mexico');document.write('<OPTION VALUE="Micronesia"> Micronesia');document.write('<OPTION VALUE="Moldiva"> Moldiva');document.write('<OPTION VALUE="Mongolia"> Mongolia');document.write('<OPTION VALUE="Montserrat"> Montserrat');document.write('<OPTION VALUE="Morocco"> Morocco');document.write('<OPTION VALUE="Mozambique"> Mozambique');document.write('<OPTION VALUE="Namibia"> Namibia');document.write('<OPTION VALUE="Nauru"> Nauru');document.write('<OPTION VALUE="Nepal"> Nepal');document.write('<OPTION VALUE="Netherland Antilles"> Netherland Antilles');document.write('<OPTION VALUE="Netherlands"> Netherlands');document.write('<OPTION VALUE="Nevis"> Nevis');document.write('<OPTION VALUE="New Calidonia"> New Calidonia');document.write('<OPTION VALUE="New Zealand"> New Zealand');document.write('<OPTION VALUE="Nicaragua"> Nicaragua');document.write('<OPTION VALUE="Niger"> Niger');document.write('<OPTION VALUE="Nigeria"> Nigeria');document.write('<OPTION VALUE="Niue Island"> Niue Island');document.write('<OPTION VALUE="Norfork Island"> Norfork Island');document.write('<OPTION VALUE="Norway"> Norway');document.write('<OPTION VALUE="Oman"> Oman');document.write('<OPTION VALUE="Pakistan"> Pakistan');document.write('<OPTION VALUE="Palau"> Palau');document.write('<OPTION VALUE="Panama"> Panama');document.write('<OPTION VALUE="Papua New Guinea"> Papua New Guinea');document.write('<OPTION VALUE="Paraguay"> Paraguay');document.write('<OPTION VALUE="Peru"> Peru');document.write('<OPTION VALUE="Philipines"> Philipines');document.write('<OPTION VALUE="Poland"> Poland');document.write('<OPTION VALUE="Portugal"> Portugal');document.write('<OPTION VALUE="Puerto Rico"> Puerto Rico');document.write('<OPTION VALUE="Qatar"> Qatar');document.write('<OPTION VALUE="Reunion Island"> Reunion Island');document.write('<OPTION VALUE="Romania"> Romania');document.write('<OPTION VALUE="Russian Federation"> Russian Federation');document.write('<OPTION VALUE="Rwanda"> Rwanda');document.write('<OPTION VALUE="Saipan"> Saipan');document.write('<OPTION VALUE="Sao Tome"> Sao Tome');document.write('<OPTION VALUE="Saudi Arabia"> Saudi Arabia');document.write('<OPTION VALUE="Senegal Republic"> Senegal Republic');document.write('<OPTION VALUE="Seychelles Island"> Seychelles Island');document.write('<OPTION VALUE="Sierrra Leone"> Sierrra Leone');document.write('<OPTION VALUE="Singapore"> Singapore');document.write('<OPTION VALUE="Slovenia"> Slovenia');document.write('<OPTION VALUE="Soloman Island"> Soloman Island');document.write('<OPTION VALUE="Somalia"> Somalia');document.write('<OPTION VALUE="South Africa"> South Africa');document.write('<OPTION VALUE="Spain"> Spain');document.write('<OPTION VALUE="Sri Lanka"> Sri Lanka');document.write('<OPTION VALUE="St. Helen"> St. Helen');document.write('<OPTION VALUE="St. Kitts"> St. Kitts');document.write('<OPTION VALUE="St. Lucia"> St. Lucia');document.write('<OPTION VALUE="St. Pierre"> St. Pierre');document.write('<OPTION VALUE="St. Vincent"> St. Vincent');document.write('<OPTION VALUE="Sudan"> Sudan');document.write('<OPTION VALUE="Suriname"> Suriname');document.write('<OPTION VALUE="Swaziland"> Swaziland');document.write('<OPTION VALUE="Sweden"> Sweden');document.write('<OPTION VALUE="Switzerland"> Switzerland');document.write('<OPTION VALUE="Syria"> Syria');document.write('<OPTION VALUE="Taiwan"> Taiwan');document.write('<OPTION VALUE="Tanzania"> Tanzania');document.write('<OPTION VALUE="Thailand"> Thailand');document.write('<OPTION VALUE="Togo"> Togo');document.write('<OPTION VALUE="Tonga"> Tonga');document.write('<OPTION VALUE="Trinidad & Tobago"> Trinidad & Tobago');document.write('<OPTION VALUE="Tunisia"> Tunisia');document.write('<OPTION VALUE="Turkey"> Turkey');document.write('<OPTION VALUE="Turks & Caicos"> Turks & Caicos');document.write('<OPTION VALUE="Tuvalu"> Tuvalu');document.write('<OPTION VALUE="Uganda"> Uganda');document.write('<OPTION VALUE="Ukraine"> Ukraine');document.write('<OPTION VALUE="United Arab Emirates"> United Arab Emirates');document.write('<OPTION VALUE="United Kingdom"> United Kingdom');document.write('<OPTION VALUE="United States" SELECTED> United States');document.write('<OPTION VALUE="Uruguay"> Uruguay');document.write('<OPTION VALUE="Vanuatu"> Vanuatu');document.write('<OPTION VALUE="Venezuela"> Venezuela');document.write('<OPTION VALUE="Viet Nam"> Viet Nam');document.write('<OPTION VALUE="West Samoa"> West Samoa');document.write('<OPTION VALUE="Yemen"> Yemen');document.write('<OPTION VALUE="Yugoslavia"> Yugoslavia');document.write('<OPTION VALUE="Zaire"> Zaire');document.write('<OPTION VALUE="Zambia"> Zambia');document.write('<OPTION VALUE="Zimbabwe"> Zimbabwe');document.write('</SELECT></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP9867039"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Phone:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="Phone" VALUE="" SIZE="" MAXLENGTH="" onkeyup="allow_numeric986703(this,\'-\');"></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP98670310"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>E-mail:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="Email" VALUE="" SIZE="45" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP98670311"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Domain Name:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="DomainName" VALUE="" SIZE="50" MAXLENGTH=""></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT>What is the domain name you would like to register or currently have.  For example: www.your-company.com</TD> ');document.write('</TR>');document.write('<TR ID="FP98670312"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Web Site Hosting?</B></TD> ');document.write('<TD ALIGN=LEFT VALIGN=TOP>');document.write('<TABLE CLASS="tableb986703">');document.write('<TR>');document.write('<TD ALIGN=LEFT VALIGN=TOP><INPUT CLASS="checkbox986703" TYPE=CHECKBOX NAME="WebSiteHosting" VALUE="Yes, I need a place to host my web site"></TD> <TD>Yes, I need a place to host my web site</TD>');document.write('</TR>');document.write('</TABLE></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT><font size=-2>One time $39 set up & activation fee.  Hosting is billed separately @ $9.95 monthly</font></TD> ');document.write('</TR>');document.write('<TR ID="FP98670313"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Free Web Design?</B></TD> ');document.write('<TD ALIGN=LEFT VALIGN=TOP>');document.write('<TABLE CLASS="tableb986703">');document.write('<TR>');document.write('<TD ALIGN=LEFT VALIGN=TOP><INPUT CLASS="checkbox986703" TYPE=CHECKBOX NAME="FreeWebDesign" VALUE="Yes, please design my web site for me"></TD> <TD>Yes, please design my web site for me</TD>');document.write('</TR>');document.write('</TABLE></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT><font size=-2>Up to 3 pages, including 10 pictures per page.  1 year commitment required. We will contact your for web site content and pictures</font></TD> ');document.write('</TR>');document.write('<TR ID="FP98670314"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Custom Logo Design?</B></TD> ');document.write('<TD ALIGN=LEFT VALIGN=TOP>');document.write('<TABLE CLASS="tableb986703">');document.write('<TR>');document.write('<TD ALIGN=LEFT VALIGN=TOP><INPUT CLASS="checkbox986703" TYPE=CHECKBOX NAME="CustomLogoDesign" VALUE="Yes, please design a logo for me"></TD> <TD>Yes, please design a logo for me</TD>');document.write('</TR>');document.write('</TABLE></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT><font size=-2>One time fee of $250 for custom logo design</font></TD> ');document.write('</TR>');document.write('<TR ID="FP98670315"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Credit Card Number:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="CreditCardNumber" VALUE="" SIZE="20" MAXLENGTH="" onkeyup="allow_numeric986703(this,\'\');"></TD>');document.write('</TR>');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR ID="FP98670316"><TD NOWRAP VALIGN=TOP ALIGN=LEFT><B>Credit Card Expiration:</B></TD> ');document.write('<TD VALIGN=TOP ALIGN=LEFT><INPUT CLASS="textbox986703" TYPE=TEXT NAME="CreditCardExpiration" VALUE="" SIZE="10" MAXLENGTH=""></TD>');document.write('');
document.write('<TR>');document.write('<TD COLSPAN=2 VALIGN=TOP ALIGN=LEFT></TD> ');document.write('</TR>');document.write('<TR><TD COLSPAN=2 VALIGN=TOP ALIGN=CENTER NOWRAP><div class="cd39357515" id="cd39357515" style="position:relative;"></div><br /><input CLASS="textbox986703" name=formprocaptcha123 size=10><br /><b>Please enter the security code above</b></TD></TR>');document.write('<script>WriteLcd39357515(\'cd39357515\',null,\'DjFDqFD{}jFDNWV\\\\(KWTWZE+NN;;AA([QbME3>FJD7NWV\\\\FD7jFD7qFD7{}jFDjFDNWV\\\\(KWTWZE+KK88;;([QbME3=FKD7NWV\\\\FD7jFDjFD{}xFDNWV\\\\(KWTWZE+>>>>88([QbME3>FND7NWV\\\\FD7jFD7{}xFDjFDNWV\\\\(KWTWZE+NNAA;;([QbME3;FWD7NWV\\\\FD7jFDjFDqFDNWV\\\\(KWTWZE+>>>>88([QbME3=F^D7NWV\\\\FD7jFD7qF\',8);</script>');document.write('<TR><TD COLSPAN=2><BR /><DIV ALIGN="CENTER"><INPUT TYPE=hidden NAME="requiredfields" VALUE="FirstName-,LastName-,City-,State-,ZipCode-Zip Code World,Country-,Phone-Phone,Email-E-mail,CreditCardNumber-Credit Card,"><INPUT TYPE=submit CLASS="textbox986703" NAME=submit VALUE="Place Order"><br /><br /><font size=-2>One time set up and activation fee of $29 if signing one year commitment, otherwise $49 one time set up and activation fee applies. $47 monthly billing will apply.</font></DIV></TD></TR>');document.write('<INPUT TYPE=HIDDEN NAME="minchars" VALUE="">');
document.write('</FORM></TABLE>');