Registration
<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0><script> (function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){ (i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o), m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m) })(window,document,'script','//www.google-analytics.com/analytics.js','ga'); ga('create', 'UA-47423994-1', 'fortunecity.ws'); ga('send', 'pageview'); </script> <center> <br> <div> <script language="javascript" type="text/javascript" src="http://ad.broadcaststation.net/ads/show_ad.php?width=728&height=90"></script> </div> </center> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=80 BGCOLOR="#000000" TEXT="#F7F7FF" bgproperties="fixed" background="03f00500dvldtc.gif"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>Busc's page</B></FONT><B> | </B><A HREF="index.htm" TARGET="_top" TITLE="Buscs page"><U><B>home</B></U></A></div> <div> <B>Registration </B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#000000" TEXT="#F7F7FF" background="040d2c00dvldtc.gif"> <bR> </td> <td valign="top" height=400 BGCOLOR="#000000" TEXT="#F7F7FF"> <div> Registration </div> <bR> <bR> <div> <!-- Start Gem --> <form action="http://formmail.trellix.com/servlets/TlxMailer" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="AH nickname,LastName,Email,Company,Address1,Address2,City,State,Zip,Phone,MailingList"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for information."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A request form was submitted"><input type="hidden" name="tlx_EmailTo" value="buscaglia@tiscalinet.it"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">AH nickname:<br> <input type="text" name="AH nickname" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Last Name:<br> <input type="text" name="LastName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Company:<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 2:<br> <input type="text" name="Address2" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">State:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Zip:<br> <input type="text" name="Zip" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td> <input type="checkbox" name="MailingList" value="yes"> Add me to your mailing list</td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form> <!-- End Gem --> </div> </td> </tr></table></body>