<center>%STATUSMSG%</center>

<form method="POST" action="register.php" />

	<table border="0" width="350">

		<tr>

			<td width="40%">Username:</td><td><input style="width:100%" type="text" name="username" /></td>

		</tr>

		<tr>

			<td width="40%">First Name:</td><td><input style="width:100%" type="text" name="firstname" /></td>

		<tr>

			<td width="40%">Last Name:</td><td><input style="width:100%" type="text" name="lastname" /></td>

		<tr>

			<td width="40%">Email:</td><td><input style="width:100%" type="text" name="email" /></td>

		<tr>

			<td width="40%">State:</td><td><input style="width:100%" type="text" name="state" /></td>

		</tr>

		<tr>

			<td colspan="2" align="center">

				%RECAPTCHA%

			</td>

		</tr>

		<tr>

			<td colspan="2"><input type="submit" value="Register" /></td>

		</tr>

		<tr>

			<td align="left"><a href="register.php?act=resend" title="Resend Confirmation">Resend Confirmation</a></td>

			<td align="right"><a href="register.php?act=recover" title="Recover Password">Recover Password</a></td>

		</tr>

	</table>

</form>