<HTML> <HEAD> <meta http-equiv="Content-Language" content="en-us"> <meta http-equiv="Content-Type" content="text/html; charset=windows-1252"> <meta name="GENERATOR" content="Microsoft FrontPage 4.0"> <meta name="ProgId" content="FrontPage.Editor.Document"> <title>Action</title> <TITLE>Customer Information</TITLE> <meta name="Microsoft Theme" content="clearday 011"> <meta name="Microsoft Border" content="none"> </HEAD> <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> <!--msthemelist--></table><!--mstheme--><font face="Verdana, Arial, Helvetica"> <!--mstheme--></font></BODY>