<html>
<head>
<title>Registration Form </title>
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<body bgcolor="#FFFFFF">
<center>
<table border="0" width="80%">
<tr>
<td align="center"><table border="0" width="100%">
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<table border="0">
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<blockquote>
<p>
<b>
<font color="#000080" size="2" face="Arial">
Registration:
</font>
</b>
<p>
<font color="#000080" size="2" face="Arial">
Please fill out the form below to create an account:
<font color="#000080" size="2" face="Arial">
<form action=pm.cgi method=post>
<input type="hidden" name="action" value="register">
<table border="0">
<tr>
<td><font color="navy" face=Arial size=2>
Login Name:
</font></td>
<td><input type="text" size="15" name="login"></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
First Name:
</font></td>
<td><input type="text" size="25" name="firstname"></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Last Name:
</font></td>
<td><input type="text" size="25" name="lastname"></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
E-mail:
</font></td>
<td><input type="text" size="25" name="email"></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Address:</font></td>
<td><textarea name="streetaddress" rows="2" cols="20"
wrap="soft"></textarea> </td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
City:
</font></td>
<td>
<input type="text" size="25" name="city">
</td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
State:
</font></td>
<td>
<select name=state>
<option></option>
<option>Alabama</option>
<option>Alaska</option>
<option>Arizona</option>
<option>Arkansas</option>
<option>California</option>
<option>Colorado</option>
<option>Connecticut</option>
<option>District of Columbia</option>
<option>Delaware</option>
<option>Florida</option>
<option>Georgia</option>
<option>Hawaii</option>
<option>Idaho</option>
<option>Illinois</option>
<option>Indiana</option>
<option>Iowa</option>
<option>Kansas</option>
<option>Kentucky</option>
<option>Louisiana</option>
<option>Maine</option>
<option>Maryland</option>
<option>Massachusetts</option>
<option>Michigan</option>
<option>Minnesota</option>
<option>Mississippi</option>
<option>Missouri</option>
<option>Montana</option>
<option>Nebraska</option>
<option>Nevada</option>
<option>New Hampshire</option>
<option>New Jersey</option>
<option>New Mexico</option>
<option>New York</option>
<option>North Carolina</option>
<option>North Dakota</option>
<option>Ohio</option>
<option>Oklahoma</option>
<option>Oregon</option>
<option>Pennsylvania</option>
<option>Rhode Island</option>
<option>South Carolina</option>
<option>South Dakota</option>
<option>Tennessee</option>
<option>Texas</option>
<option>Utah</option>
<option>Vermont</option>
<option>Virginia</option>
<option>Washington</option>
<option>West Virginia</option>
<option>Wisconsin</option>
<option>Wyoming</option>
<option>Alberta</option>
<option>British Columbia</option>
<option>Manitoba</option>
<option>New Brunswick</option>
<option>Newfoundland</option>
<option>Northwest Territories</option>
<option>Nova Scotia</option>
<option>Nunavut</option>
<option>Ontario</option>
<option>Prince Edward Island</option>
<option>Quebec</option>
<option>Saskatchewan</option>
<option>Yukon</option>
</select>
</td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Post Code:
</font></td>
<td>
<input type="text" size="6" name="postcode">
</td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Country:
</font></td>
<td>
<select name=country>
<option></option>
<option>United States of America</option>
<option>Canada</option>
<option>Afghanistan</option>
<option>Albania</option>
<option>Algeria</option>
<option>American Samoa</option>
<option>Andorra</option>
<option>Angola</option>
<option>Anguilla</option>
<option>Antarctica</option>
<option>Antigua and Barbuda</option>
<option>Argentina</option>
<option>Armenia</option>
<option>Australia</option>
<option>Austria</option>
<option>Azerbaijan</option>
<option>Bahamas</option>
<option>Bahrain</option>
<option>Bangladesh</option>
<option>Barbados</option>
<option>Belarus</option>
<option>Belgium</option>
<option>Belize</option>
<option>Bermuda</option>
<option>Bhutan</option>
<option>Bolivia</option>
<option>Bosnia and Herzegovina</option>
<option>Botswana</option>
<option>Brazil</option>
<option>Brunei Darussalam</option>
<option>Bulgaria</option>
<option>Burkina Faso</option>
<option>Burundi</option>
<option>Cambodia</option>
<option>Cameroon</option>
<option>Canada</option>
<option>Central African Republic</option>
<option>Chad</option>
<option>Chile</option>
<option>China</option>
<option>Colombia</option>
<option>Congo</option>
<option>Cook Islands</option>
<option>Costa Rica</option>
<option>Croatia (Hrvatska)</option>
<option>Cuba</option>
<option>Cyprus</option>
<option>Czech Republic</option>
<option>Denmark</option>
<option>Djibouti</option>
<option>Dominica</option>
<option>Dominican Republic</option>
<option>East Timor</option>
<option>Ecuador</option>
<option>Egypt</option>
<option>El Salvador</option>
<option>Equatorial Guinea</option>
<option>Eritrea</option>
<option>Estonia</option>
<option>Ethiopia</option>
<option>Fiji</option>
<option>Finland</option>
<option>France</option>
<option>French Guiana</option>
<option>French Polynesia</option>
<option>French Southern Territories</option>
<option>Gabon</option>
<option>Gambia</option>
<option>Georgia</option>
<option>Germany</option>
<option>Ghana</option>
<option>Gibraltar</option>
<option>Greece</option>
<option>Greenland</option>
<option>Grenada</option>
<option>Guadeloupe</option>
<option>Guam</option>
<option>Guatemala</option>
<option>Guinea</option>
<option>Guinea-Bissau</option>
<option>Guyana</option>
<option>Haiti</option>
<option>Honduras</option>
<option>Hong Kong</option>
<option>Hungary</option>
<option>Iceland</option>
<option>India</option>
<option>Indonesia</option>
<option>Iran (Islamic Republic of)</option>
<option>Iraq</option>
<option>Ireland</option>
<option>Israel</option>
<option>Italy</option>
<option>Jamaica</option>
<option>Japan</option>
<option>Jordan</option>
<option>Kazakhstan</option>
<option>Kenya</option>
<option>Korea, Democratic Peoples Republic of</option>
<option>Korea, Republic of</option>
<option>Kuwait</option>
<option>Kyrgyzstan</option>
<option>Lao Peoples Democratic Republic</option>
<option>Latvia</option>
<option>Lebanon</option>
<option>Lesotho</option>
<option>Liberia</option>
<option>Libyan Arab Jamahiriya</option>
<option>Liechtenstein</option>
<option>Lithuania</option>
<option>Luxembourg</option>
<option>Macau</option>
<option>Macedonia</option>
<option>Madagascar</option>
<option>Malawi</option>
<option>Malaysia</option>
<option>Martinique</option>
<option>Mauritania</option>
<option>Mauritius</option>
<option>Mexico</option>
<option>Micronesia, Federated States Of</option>
<option>Moldova, Republic of</option>
<option>Monaco</option>
<option>Mongolia</option>
<option>Morocco</option>
<option>Mozambique</option>
<option>Namibia</option>
<option>Nepal</option>
<option>Netherlands</option>
<option>Netherlands Antilles</option>
<option>New Caledonia</option>
<option>New Zealand</option>
<option>Nicaragua</option>
<option>Niger</option>
<option>Nigeria</option>
<option>Norway</option>
<option>Oman</option>
<option>Pakistan</option>
<option>Panama</option>
<option>Papua New Guinea</option>
<option>Paraguay</option>
<option>Peru</option>
<option>Philippines</option>
<option>Poland</option>
<option>Portugal</option>
<option>Puerto Rico</option>
<option>Romania</option>
<option>Russian Federation</option>
<option>Rwanda</option>
<option>Samoa</option>
<option>Saudi Arabia</option>
<option>Senegal</option>
<option>Seychelles</option>
<option>Sierra Leone</option>
<option>Singapore</option>
<option>Slovakia (Slovak Republic)</option>
<option>Slovenia</option>
<option>Somalia</option>
<option>South Africa</option>
<option>South Georgia</option>
<option>Spain</option>
<option>Sri Lanka</option>
<option>Sudan</option>
<option>Suriname</option>
<option>Swaziland</option>
<option>Sweden</option>
<option>Switzerland</option>
<option>Syrian Arab Republic</option>
<option>Taiwan</option>
<option>Tajikistan</option>
<option>Tanzania, United Republic of</option>
<option>Thailand</option>
<option>Togo</option>
<option>Tonga</option>
<option>Trinidad and Tobago</option>
<option>Tunisia</option>
<option>Turkey</option>
<option>Turkmenistan</option>
<option>Uganda</option>
<option>Ukraine</option>
<option>United Arab Emirates</option>
<option>United Kingdom</option>
<option>United States of America</option>
<option>Uruguay</option>
<option>Uzbekistan</option>
<option>Vatican City State (Holy See)</option>
<option>Venezuela</option>
<option>Viet Nam</option>
<option>Virgin Islands (British)</option>
<option>Virgin Islands (U.S.)</option>
<option>Western Sahara</option>
<option>Yemen</option>
<option>Yugoslavia</option>
<option>Zaire</option>
<option>Zambia</option>
<option>Zimbabwe</option>
</select>
</td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Phone:
</font></td>
<td><input type="text" size="15" name="tel"></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Date of Birth:
</font></td>
<td>
<select name="birthday">
<option selected></option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
</select>
<select name="birthmonth">
<option selected></option>
<option>January</option>
<option>February</option>
<option>March</option>
<option>April</option>
<option>May</option>
<option>June</option>
<option>July</option>
<option>August</option>
<option>September</option>
<option>October</option>
<option>November</option>
<option>December</option>
</select>
<select name="birthyear">
<option selected></option>
<option>1999</option>
<option>1998</option>
<option>1997</option>
<option>1996</option>
<option>1995</option>
<option>1994</option>
<option>1993</option>
<option>1992</option>
<option>1991</option>
<option>1990</option>
<option>1989</option>
<option>1988</option>
<option>1987</option>
<option>1986</option>
<option>1985</option>
<option>1984</option>
<option>1983</option>
<option>1982</option>
<option>1981</option>
<option>1980</option>
<option>1979</option>
<option>1978</option>
<option>1977</option>
<option>1976</option>
<option>1975</option>
<option>1974</option>
<option>1973</option>
<option>1972</option>
<option>1971</option>
<option>1970</option>
<option>1969</option>
<option>1968</option>
<option>1967</option>
<option>1966</option>
<option>1965</option>
<option>1964</option>
<option>1963</option>
<option>1962</option>
<option>1961</option>
<option>1960</option>
<option>1959</option>
<option>1958</option>
<option>1957</option>
<option>1956</option>
<option>1955</option>
<option>1954</option>
<option>1953</option>
<option>1952</option>
<option>1951</option>
<option>1950</option>
<option>1949</option>
<option>1948</option>
<option>1947</option>
<option>1946</option>
<option>1945</option>
<option>1944</option>
<option>1943</option>
<option>1942</option>
<option>1941</option>
<option>1940</option>
<option>1939</option>
<option>1938</option>
<option>1937</option>
<option>1936</option>
<option>1935</option>
<option>1934</option>
<option>1933</option>
<option>1932</option>
</select>
</td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>Gender:</td>
<td><select name="gender" size="1">
<option value=" ">
<option value="Male"> Male </option>
<option value="Female"> Female </option>
</select></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>Marital Status:</td>
<td><select name="status" size="1">
<option value=" ">
<option value="single"> Single </option>
<option value="married"> Married </option>
</select></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Occupation:
</font></td>
<td><input type="text" size="25" name="occupation"></td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Favorite Quote:</font></td>
<td><textarea name="quote" rows="3" cols="30"
wrap="soft"></textarea> </td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Hobbies:</font></td>
<td><textarea name="hobbies" rows="3" cols="30"
wrap="soft"></textarea> </td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
News:</font></td>
<td><textarea name="news" rows="3" cols="30"
wrap="soft"></textarea> </td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
Homepage:
</font></td>
<td><input type="text" size="35" name="homepage"></td>
</tr>
<tr>
<td>
<font size=2 face=arial color=navy>
Receive Newsletters
</font>
</td>
<td>
<input type=checkbox name=mailing value=yes>
</td>
</tr>
<tr>
<td><font color="navy" face=Arial size=2>
<INPUT type="submit" name="submit" value="Register">
</form></td> </tr>
</table>
</blockquote>
</td>
</tr>
</table>
</td>
</tr>
</table>
</table>
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