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web-hack-mirror/mirror/2000/02/13/www.guidingservice.co.il/form.htm

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<html>
<head>
<title>CHAIM MAOZ</title>
</head>
<body background="images/f.jpg" vlink="#000000" alink="#0000FF">
<div align="center"><center>
<table border="0" width="600" cellspacing="0" cellpadding="0">
<tr>
<td width="100%"><p align="center"><img src="images/title.gif" WIDTH="336" HEIGHT="51"><br>
<img src="images/israel.gif" WIDTH="68" HEIGHT="50"></td>
</tr>
</table>
</center></div><div align="center"><center>
<table border="0" width="600" cellspacing="0" cellpadding="0">
<tr>
<td width="100%" height="10">&nbsp;<form method="POST" action="_vti_bin/shtml.dll/form.htm" webbot-action="--WEBBOT-SELF--">
<!--webbot bot="SaveResults" S-Email-Format="TEXT/PRE" S-Email-Address="maoz_ch@netvision.net.il" B-Email-Label-Fields="TRUE" B-Email-Subject-From-Field="FALSE" S-Email-Subject="Maoz site" S-Builtin-Fields="Date Time" S-Form-Fields="first_name address last_name phone Email fax more_info More_information " U-Confirmation-Url="confirm.htm" startspan --><input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--webbot bot="SaveResults" endspan i-checksum="43374" --><table border="0" width="622" cellspacing="0" cellpadding="5">
<tr>
<td width="592" align="left" bgcolor="#7F7F7F" colspan="5"><div align="center"><center><p><img src="images/thank.gif" WIDTH="423" HEIGHT="28"></td>
</tr>
<tr>
<td width="133" align="left" bgcolor="#7F7F7F">FIRST NAME:</td>
<td width="170" align="right" bgcolor="#7F7F7F"><input type="text" name="first_name" size="20"></td>
<td width="23" bgcolor="#7F7F7F"><font color="#7F7F7F">.</font></td>
<td width="65" bgcolor="#7F7F7F">ADDRESS:</td>
<td width="201" bgcolor="#7F7F7F"><input type="text" name="address" size="20"></td>
</tr>
<tr>
<td width="133" align="left" bgcolor="#7F7F7F">LAST NAME:</td>
<td width="170" align="right" bgcolor="#7F7F7F"><input type="text" name="last_name" size="20"></td>
<td width="23" bgcolor="#7F7F7F"><font color="#7F7F7F">.</font></td>
<td width="65" bgcolor="#7F7F7F">TEL:</td>
<td width="201" bgcolor="#7F7F7F"><input type="text" name="phone" size="20"></td>
</tr>
<tr>
<td width="133" align="left" bgcolor="#7F7F7F">E-MAIL:</td>
<td width="170" align="right" bgcolor="#7F7F7F"><input type="text" name="Email" size="20"></td>
<td width="23" bgcolor="#7F7F7F"><font color="#7F7F7F">.</font></td>
<td width="65" bgcolor="#7F7F7F">FAX:</td>
<td width="201" bgcolor="#7F7F7F"><input type="text" name="fax" size="20"></td>
</tr>
<tr>
<td width="562" colspan="5" height="20" bgcolor="#7F7F7F"><font color="#7F7F7F">.</font></td>
</tr>
<tr>
<td width="562" colspan="5" bgcolor="#A7A7A7"><div align="center"><center><p><img src="images/interested.gif" WIDTH="343" HEIGHT="27"></td>
</tr>
<tr align="center">
<td width="562" colspan="5" bgcolor="#A7A7A7"><table border="0" width="100%" cellspacing="0" cellpadding="0">
<tr>
<td width="25%"><input type="radio" value="intersted_in_families" name="more_info">FAMILIES</td>
<td width="33%"><input type="radio" value="interested_in_barMitsva" name="more_info">BAR/BAT
MITZVAH</td>
<td width="42%"><input type="radio" value="interested_in_honeyMoon" name="more_info">SMALL
GROUP (2 to 11 pax)</td>
</tr>
</table>
</td>
</tr>
<tr align="center">
<td width="562" colspan="5" height="20" bgcolor="#A7A7A7"><font color="#A7A7A7">.</font></td>
</tr>
<tr align="center">
<td width="562" colspan="5" bgcolor="#E1E1E1"><div align="center"><center><p><img src="images/comments.gif" WIDTH="355" HEIGHT="25"></td>
</tr>
<tr align="center">
<td width="562" colspan="5" bgcolor="#E1E1E1"><div align="center"><center><p><textarea rows="6" name="More_information" cols="54"></textarea></td>
</tr>
<tr align="center">
<td width="562" colspan="5" bgcolor="#E1E1E1"><div align="center"><center><p><input type="submit" value="Submit" name="submit"><input type="reset" value="Reset" name="B2"></td>
</tr>
</table>
</form>
</td>
</tr>
</table>
</center></div><div align="center"><center>
<table border="0" width="600" cellspacing="0" cellpadding="0" height="40">
<tr>
<td width="100%"><p align="center"><a href="index.html"><font size="2">Back to the home
page</font></a></td>
</tr>
</table>
</center></div>
</body>
</html>