<![CDATA[
<html>
<head>
<title>yourdomain Online order Form</title>
</head>
<body bgcolor=#FFFFFF text=#000000>
<center>
<h1>yourdomain Online Order Form</h1>
</center>
<p><hr size=7 width=75%><p>
<form method=POST action="http://yourdomain.com/cgi-bin/cgiemail/forms/order.txt">
<INPUT TYPE=HIDDEN VALUE="http://yourdomain.com/" name="success">
<INPUT TYPE=HIDDEN name="required-to" size=25 value="yourdomain@yourdomain.com">
<INPUT TYPE=HIDDEN VALUE="yourdomain Order form" name="subject">
<center>
<table border>
<tr>
<th align=left>Name: </th><td><input type=text name="name" size=40><br></td>
</tr><tr>
<th align=left>E-Mail: </th><td><input type=text name="email" size=40><br></td>
</tr><tr>
<th align=left>Company: </th><td><input type=text name="company" size=40><br></td>
</tr><tr>
<th align=left>Street Address: </th><td><input type=text name="street" size=40><br></td>
</tr><tr>
<th align=left>City, State, Zip: </th><td><input type=text name="city" size=20>, <input type=text name="state" size=2 maxlength=2> <input type=text name="zip" size=10 maxlength=10><br></td> </tr>
</tr><tr>
<th align=left>Phone: </th><td><input type=text name="phone" size=12 maxlength=12><br></td>
</tr><tr>
<th align=left>Services Requested: </th><td><select name="number">
<option selected>
<option>Basic Services $29.95
<option>Business Services $49.95
<option>Advanced Services $79.95
<option>Other
</select> If Other: <input type=text name="amount" size=10><br></td>
</tr><tr>
<th align=left>Comments: </th><td><textarea COLS=40 ROWS=4 name="comments"></textarea><br></td>
</tr><tr>
<td><STRONG>Payment Type</STRONG></td>
<td align=center><input type=radio name="type" value="MC">MasterCard <input type=radio name="type" value="Visa"> Visa <input type=radio name="type" value="Amex"> Amex
</tr><tr>
<td><STRONG>Credit Card number</STRONG></td>
<td><input type=text name="card" size=30> exp:<input type=text name="exp" size=10>
</tr><tr>
<th colspan=2><input type=submit value="Submit"> <input type=reset><br></th> </tr>
</table>
</center>
<p><hr size=7 width=75%><br>
<ul>
<li><a href="./">yourdomain</a>
</ul>
</body></html>
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