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<html>
<head><title>Cure Arthritis Contact Form</title></head>
<body bgcolor="#FFE1F0">
<div align="center">
<table border="0" cellpadding="0" cellspacing="0" width="600">
<tr>
<td width="100"><a href="index.htm"><img src="IMAGES/ANR_logo-lav.gif" alt="To main menu" align="baseline" border="0" hspace="3" width="80" height="82"></a></td>
<td width="500"><font size="4" color="#400080"><strong>Please Enter Your Information Directly Below....</strong></font></td>
</tr>
</table>
</div>
<!--Modified by Devin -->
<form method="POST" name="contact" action="mailcontact.asp">
<p><font face="Times New Roman" size="4"><strong><i>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Your Information:</i></strong></font></p>
<div align="center">
<table border="0" cellspacing="0" width="600">
<tr>
<td width="100" align="right"><b>Name:</b></td>
<td width="500" colspan="5"><b><input type="text" size="35" maxlength="35" name="Name" tabindex="1"></b></td>
</tr>
<tr>
<td width="100" align="right"><b>Address:</b></td>
<td width="500" colspan="5"><b><input type="text" size="35" maxlength="35" name="Address" tabindex="2"></b></td>
</tr>
<tr>
<td width="100" align="right"><b>City:</b></td>
<td width="500" colspan="5"><b><input type="text" size="35" maxlength="35" name="City" tabindex="3"></b></td>
</tr>
<tr>
<td width="100" align="right"><b>State:</b></td>
<td width="100"><select name="States" size="1" tabindex="4">
<option value="AK">AK</option><option value="AS">AS</option><option value="AS">AS</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="FM">FM</option><option value="FL">FL</option><option value="GA">GA</option><option value="GU">GU</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="MH">MH</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="MP">MP</option><option value="OH">OH</option><option value="OK">OK</option><option value="OR">OR</option><option value="PW">PW</option><option value="PA">PA</option><option value="PR">PR</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="VI">VI</option><option value="VA">VA</option><option value="WA">WA</option><option value="WV">WV</option><option value="WI">WI</option><option value="WY">WY</option>
</select></td>
<td width="100"><div align="right"><p><b>Zip Code:</b></td>
<td width="60" align="right"><b><input type="text" size="12" maxlength="35" name="Zipcode" tabindex="5"></b></td>
<td width="100" align="right"><b>Country:</b></td>
<td width="100"><b><input type="text" size="12" maxlength="12" name="Country" tabindex="6"></b></td>
</tr>
<tr>
<td width="100" align="right"><b>Phone:</b></td>
<td width="200" colspan="2"><b><input type="text" size="18" maxlength="35" name="Phone" tabindex="7"></b></td>
<td width="50" align="right"><div align="right"><p><b>Fax:</b></td>
<td width="250" align="right" colspan="2"><div align="left"><p><b><input type="text" size="18" maxlength="35" name="Fax" tabindex="8"></b></td>
</tr>
<tr>
<td width="100" align="right"><b>E-mail:</b></td>
<td width="500" colspan="5"><b><input type="text" size="35" maxlength="35" name="Email" tabindex="9"></b></td>
</tr>
</table>
<table border="0" cellspacing="0" width="600">
<tr>
<td colspan="2" width="600"><b>I am interested in:</b></td>
</tr>
<tr>
<td width="100" align="right"><input type="checkbox" name="Interestedin1" value="make a contribution" tabindex="10"></td>
<td width="500"><font size="2" face="Courier New"><strong>Making a Contribution <a href="giving.htm">TO DONATION FORM</a></strong></font></td>
</tr>
<tr>
<td width="100" align="right"><input type="checkbox" name="Interestedin2" value="estate planning" tabindex="11"></td>
<td width="500"><font size="2" face="Courier New"><strong>Estate Planning Information</strong></font></td>
</tr>
<tr>
<td width="100" align="right"><input type="checkbox" name="Interestedin3" value="apply for a grant" tabindex="12"></td>
<td width="500"><font size="2" face="Courier New"><strong>Applying for a Grant</strong></font></td>
</tr>
<tr>
<td width="100" align="right"><input type="checkbox" name="Interestedin4" value="more research info" tabindex="13"></td>
<td width="500"><font size="2" face="Courier New"><strong>More Information on Research</strong></font></td>
</tr>
<tr>
<td width="100" align="right"><input type="checkbox" name="Interestedin5" value="golf tournament" tabindex="14"></td>
<td width="500"><font size="2" face="Courier New"><strong>Golf Tournament- 2000</strong></font></td>
</tr>
<tr>
<td width="600" align="right" colspan="2"><div align="left"><p><b>Please feel free to sendus a message with your request.</b></td>
</tr>
<tr>
<td width="600" align="right" colspan="2"><div align="center"><center><p><textarea name="Message" rows="8" cols="64" tabindex="15"></textarea></td>
</tr>
<tr align="center">
<td width="600" align="right" colspan="2"></td>
</tr>
</table>
<table border="0" cellspacing="0" width="600">
<tr>
<td width="200"><b>Please reply by:</b></td>
<td width="50"><div align="right"><p><b><input type="radio" name="Send Matchlist Via" value="Mail" tabindex="16"></b></td>
<td width="100"><b>Mail:</b></td>
<td width="50"><div align="right"><p><b><input type="radio" name="Send Matchlist Via" value="Email" tabindex="17" checked></b></td>
<td width="100"><b>Email:</b></td>
<td width="50"><div align="right"><p><b><input type="radio" name="Send Matchlist Via" value="Phone" tabindex="18"></b></td>
<td width="100"><b>Phone:</b></td>
<td width="50"><div align="right"><p><b><input type="radio" name="Send Matchlist Via" value="Fax" tabindex="19"></b></td>
<td width="100"><b>Fax:</b></td>
</tr>
</table>
<p><input type="submit" value="Submit"><input type="RESET" value="Clear Form"></p>
</div>
</form>
<!--end modified by Devin -->
<p align="center"><font face="Times New Roman" size="5" color="#400080"><strong><em><i>We will be contacting you shortly.</i></em></strong></font></p>
<p align="center"><a href="about.htm">[Meet the ANRF]</a> <a href="whatis.htm">[Latest Research]</a> <a href="cureart1.htm">[<em>Cure</em>Arthritis Newsletter]</a>
<a href="giving.htm">[Support the Research]</a> <a href="donors.htm">[Our Sponsors]</a><br>
<a href="grant.htm">[Grant Application Guidelines</a> <a href="cureart1.htm">[<em>Cure</em>Arthritis Newsletter]</a> <a href="useful.htm">[Arthritis Info &amp; Links]</a> <a href="contact.htm">[Contact Us]</a></p>
<p align="center">&nbsp;</p>
<p align="center"><font face="Arial">The information provided in the Arthritis National Research Foundation&#146;s web page is for educational purposes only. It is not designed to provide medical advice. The foundation provides funding for young investigators seeking the causes and treatment of rheumatic diseases. Please consult your own healthcare provider regarding any medical issues relating to diseases, conditions, symptoms, diagnosis, treatments and side effects. </font></p>
</body>
</html>