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web-hack-mirror/mirror/2000/03/24/www.south-seas-resort.com/ssr-req.html

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<!DOCTYPE HTML PUBLIC "-//IETF//DTD HTML//EN">
<html>
<head>
<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
<title>SSR Request A Brochure</title>
</head>
<body bgcolor="#FFFFFF" link="#0000B9" vlink="#B4000F" alink="#F89907">
<form action="http://www.southseas.com/scripts/mailpost.exe/brocmain.txt" method="POST">
<input type="hidden" name="success" value="http://www.southseasplantation.com/thankyou.html"><div align="center"><center><table border="0">
<tr>
<td><div align="center"><center><p><img src="images/talkback.rq.jpg" naturalsizeflag="3" WIDTH="422" HEIGHT="271"> </p>
</center></div><div align="left"><h3><input type="checkbox" name="South Seas Resort" value="req_ssp" checked><font size="3">I want to know more! Send me South Seas Resort
brochures.<br>
(fields in red are required)</font></h3>
</div><div align="left"><h3><font size="3"><b><font color="#FF0000">Title</font></b> <b><select name="required-title" size="1">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Ms.">Ms.</option>
<option value="Mr. and Mrs.">Mr. and Mrs.</option>
<option value="Miss">Miss</option>
<option value="Dr.">Dr.</option>
<option value="Dr. and Mrs.">Dr. and Mrs.</option>
<option value="Dr. and Dr.">Dr. and Dr.</option>
<option value="Mr. and Dr.">Mr. and Dr.</option>
<option value="Father">Father</option>
<option value="Sister">Sister</option>
<option value="Pastor">Pastor</option>
<option value="Reverend">Reverend</option>
<option value="Rabbi">Rabbi</option>
</select></b>&nbsp; <font color="#FF0000"><b>First Name</b></font> <b><input type="text" size="12" maxlength="256" name="required-first"></b><br>
<b>Middle Initial </b> <b><input type="text" size="1" maxlength="256" name="initial"></b>
&nbsp;&nbsp; <font color="#FF0000"><b>Last Name</b></font> <input type="text" size="15" maxlength="256" name="required-last"><br>
<b>Company Name <input type="text" size="25" maxlength="256" name="address1"><br>
<font color="#FF0000">Street Address</font> <input type="text" size="25" maxlength="256" name="required-address2"><br>
<font color="#FF0000">City</font> <input type="text" size="25" maxlength="256" name="required-city">&nbsp; <font color="#FF0000">State</font> </b><select name="required-state" size="1">
<option selected>NONE</option>
<option>AL</option>
<option>AK</option>
<option>AZ</option>
<option>AR</option>
<option>CA</option>
<option>CO</option>
<option>CT</option>
<option>DE</option>
<option>DC</option>
<option>FL</option>
<option>GA</option>
<option>HI</option>
<option>ID</option>
<option>IL</option>
<option>IN</option>
<option>IA</option>
<option>KS</option>
<option>KY</option>
<option>LA</option>
<option>ME</option>
<option>MD</option>
<option>MA</option>
<option>MI</option>
<option>MN</option>
<option>MO</option>
<option>MS</option>
<option>MT</option>
<option>NE</option>
<option>NV</option>
<option>NH</option>
<option>NJ</option>
<option>NM</option>
<option>NY</option>
<option>NC</option>
<option>ND</option>
<option>OH</option>
<option>OK</option>
<option>OR</option>
<option>PA</option>
<option>PR</option>
<option>RI</option>
<option>SC</option>
<option>SD</option>
<option>TN</option>
<option>TX</option>
<option>UT</option>
<option>VT</option>
<option>VA</option>
<option>VI</option>
<option>WA</option>
<option>WV</option>
<option>WI</option>
<option>WY</option>
</select><b><br>
<font color="#FF0000">Zip Code</font> <input type="text" size="10" maxlength="256" name="required-zip">&nbsp;&nbsp; Country </b><input type="text" size="10" maxlength="256" name="country"><b><br>
Home Phone <input type="text" size="10" maxlength="256" name="home">&nbsp;&nbsp; Business
Phone <input type="text" size="10" maxlength="256" name="work"><br>
Fax <input type="text" size="10" maxlength="256" name="fax"><br>
Register your e-mail address to receive special offers and discounts:<br>
<input type="text" size="25" maxlength="256" name="email"></b></font></h3>
</div><div align="center"><center><h3><input type="submit" name="submit" value="Send Information"><br>
</h3>
</center></div></td>
</tr>
</table>
</center></div>
</form>
<div align="center"><center>
<table border="0" width="484">
<tr>
<td><p align="center"><font face="Arial" size="2" color="#000080"><a href="home.html">Home</a>
</font></p>
<p align="center"><img src="images/ssrctag.gif" alt="ssrctag.gif (1588 bytes)" WIDTH="229" HEIGHT="48"></td>
</tr>
</table>
</center></div>
</body>
</html>