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<title>Action</title>
<TITLE>Customer Information</TITLE>
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<BODY background="_themes/clearday/cdbkgnd.jpg" bgcolor="#FFFFFF" text="#000000" link="#0033CC" vlink="#6699FF" alink="#00CC33"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<H1><!--mstheme--><font color="#000099">Customer Information<!--mstheme--></font></H1>
<!--msthemeseparator--><p align="center"><img src="_themes/clearday/acdrule.gif" width="600" height="10"></p>
<P>
Customer Information Page</P>
<FORM METHOD="POST" ACTION="custom.php3">
<!--mstheme--></font><!--msthemelist--><table border="0" cellpadding="0" cellspacing="0" width="100%">
<!--msthemelist--><tr><td valign="baseline" width="42"><img src="_themes/clearday/acdbull1.gif" width="15" height="15" hspace="13"></td><td valign="top" width="100%"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<P>
Please provide the following contact information:</P>
<!--mstheme--></font><TABLE>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Name</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_FullName" SIZE=30 tabindex="1">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Street Address</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_StreetAddress" SIZE=50 tabindex="2">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Address (cont.)</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_Address2" SIZE=50 tabindex="3">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>City</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_City" SIZE=20 tabindex="4">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>State/Province</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_State" SIZE=2 tabindex="5">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Zip/Postal Code</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_ZipCode" SIZE=5 MAXLENGTH=5 tabindex="6">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM> Phone</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_WorkPhone" SIZE=10 MAXLENGTH=10 tabindex="7">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>E-mail</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Contact_Email" SIZE=35 tabindex="8">
<!--mstheme--></font></TD>
</TR>
</TABLE><!--mstheme--><font face="Verdana, Arial, Helvetica">
<br>
<!--msthemelist--><tr><td valign="baseline" width="42"><img src="_themes/clearday/acdbull1.gif" width="15" height="15" hspace="13"></td><td valign="top" width="100%"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<P>
Please provide the following ordering information:</P>
<!--mstheme--></font><TABLE>
<TR>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica"><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<STRONG>SHIPPING</STRONG><!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Street Address</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Ordering_StreetAddress" SIZE=50 tabindex="9">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Address (cont.)</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Ordering_Address2" SIZE=50 tabindex="10">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>City</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Ordering_City" SIZE=20 tabindex="11">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>State/Province</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Ordering_State" SIZE=2 tabindex="12">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Zip/Postal Code</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Ordering_ZipCode" SIZE=5 MAXLENGTH=5 tabindex="13">
<!--mstheme--></font></TD>
</TR>
</TABLE><!--mstheme--><font face="Verdana, Arial, Helvetica">
<br>
<!--msthemelist--><tr><td valign="baseline" width="42"><img src="_themes/clearday/acdbull1.gif" width="15" height="15" hspace="13"></td><td valign="top" width="100%"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<P>
Please provide a username and password:</P>
<!--mstheme--></font><TABLE>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Username</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT NAME="Username" SIZE=16 tabindex="14">
<!--mstheme--></font></TD>
</TR>
<TR>
<TD ALIGN="right"><!--mstheme--><font face="Verdana, Arial, Helvetica">
<EM>Password</EM><!--mstheme--></font></TD>
<TD><!--mstheme--><font face="Verdana, Arial, Helvetica">
<INPUT TYPE=password NAME="Password" SIZE=16 tabindex="15">
<!--mstheme--></font></TD>
</TR>
</TABLE><!--mstheme--><font face="Verdana, Arial, Helvetica">
<br>
<INPUT TYPE=SUBMIT VALUE="Submit Form">
<INPUT TYPE=RESET VALUE="Reset Form">
</FORM>
<!--msthemeseparator--><p align="center"><img src="_themes/clearday/acdrule.gif" width="600" height="10"></p>
<H5><!--mstheme--><font color="#000099">Copyright © 1999 [Dreamland]. All rights reserved. <BR>
Revised: <!--WEBBOT bot=TimeStamp
S-Type="EDITED"
S-Format="%B %d, %Y" startspan
-->December 17, 1999<!--WEBBOT bot=TimeStamp endspan i-checksum="41193"
--><!--mstheme--></font></H5>
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