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<!DOCTYPE HTML PUBLIC "-//IETF//DTD HTML//EN">
<html>
<head>
<meta http-equiv="Content-Type"
content="text/html; charset=iso-8859-1">
<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
<title>Samaritan's Purse Registration</title>
<meta name="FORMATTER" content="Microsoft FrontPage 2.0">
</head>
<body stylesrc="spintro.htm" bgcolor="#FFFFCC" text="#000000"
link="#008080" vlink="#CC0000" alink="#003399">
<h3 align="center"><font color="#000000" size="6" face="Arial">Samaritan's
Purse Registration Form</font></h3>
<hr>
<form method="POST" action="_vti_bin/shtml.dll/spregis.htm"
webbot-action="--WEBBOT-SELF--">
<!--webbot bot="SaveResults"
u-file="registration_results.txt" s-format="TEXT/CSV"
s-label-fields="TRUE"
s-builtin-fields="Date Time REMOTE_NAME REMOTE_USER HTTP_USER_AGENT"
s-form-fields startspan --><input type="hidden"
name="VTI-GROUP" value="0"><!--webbot bot="SaveResults"
endspan i-checksum="52487" --><input type="hidden"
name="VTI-GROUP" value="0"><blockquote>
<p><font face="Arial">If you would like to be added to
our mailing list, please provide us with the following
information. <br>
<font size="2"><strong>(USE THE TAB KEY TO MOVE AROUND
FIELDS):</strong></font></font></p>
</blockquote>
<blockquote>
<div align="left"><pre><font face="Arial"><font size="3"> </pre>
</div><table border="0" cellpadding="2" cellspacing="0"
width="600">
<tr>
<td align="right">Title</td>
<td></td>
<td align="left"></font><select name="Title"
size="1">
<option>Mr.</option>
<option>Mrs.</option>
<option>Miss</option>
<option>Dr.</option>
<option>Rev.</option>
</select></td>
</tr>
<tr>
<td align="right"></font><font size="3"
face="Arial">First name</font></td>
<td></td>
<td align="left"><input type="text" size="25"
maxlength="256" name="Contact_FirstName"></td>
</tr>
<tr>
<td align="right">Last name</td>
<td></td>
<td align="left"><input type="text" size="25"
maxlength="256" name="Contact_LastName"></td>
</tr>
<tr>
<td align="right">Middle initial</td>
<td></td>
<td align="left"><input type="text" size="4"
maxlength="1" name="Contact_MiddleInitial"></td>
</tr>
<tr>
<td align="right">Street address</td>
<td></td>
<td align="left"><input type="text" size="35"
maxlength="256" name="Contact_StreetAddress"></td>
</tr>
<tr>
<td align="right">Address (cont.)</td>
<td></td>
<td align="left"><input type="text" size="35"
maxlength="256" name="Contact_Address2"></td>
</tr>
<tr>
<td align="right">City</td>
<td></td>
<td align="left"><input type="text" size="35"
maxlength="256" name="Contact_City"></td>
</tr>
<tr>
<td align="right">State/Province</td>
<td></td>
<td align="left"><input type="text" size="14"
maxlength="256" name="State"></td>
</tr>
<tr>
<td align="right">Zip/Postal code</td>
<td></td>
<td align="left"><input type="text" size="12"
maxlength="12" name="Contact_ZipCode"></td>
</tr>
<tr>
<td align="right">Country</td>
<td></td>
<td align="left"><input type="text" size="25"
maxlength="256" name="Contact_Country"></td>
</tr>
<tr>
<td align="right">E-mail address</td>
<td></td>
<td align="left"><input type="text"
name="Contact_Email" size="35"></td>
</tr>
<tr>
<td align="left" colspan="3"></td>
</tr>
</table>
<div align="left"><p>&nbsp;</p>
</div>
</blockquote>
<hr>
<div align="center"><center><p><input type="submit"
name="Submit_Button" value="Submit Form"> <input type="reset"
value="Reset Form"> </p>
</center></div>
</form>
<p>Z000-WWW0</p>
<hr>
<p align="center"><a href="default.htm">Home</a></p>
<hr>
<h5 align="center">This Page last updated <!--webbot
bot="Timestamp" s-type="EDITED" s-format="%m/%d/%y" startspan -->10/12/99<!--webbot
bot="Timestamp" endspan i-checksum="13973" --></h5>
<h5 align="center"><font color="#808080" face="Arial" size="1"><i>Contents
of this site, including graphics and text (unless otherwise
noted), <br>
are copyright©1999 by Samaritan's Purse. All rights reserved.</i>
</font><font size="3" face="Arial"></h5>
</font>
</body>
</html>