<html> <body> </body> </html> <center><b><i><font size="7"><font color="red">PLEDGE FORM</center></b></i></font> <center><font size="3"><font color"black"><i><b>Please fill out this form and send a check to:<br><font color="blue"> Ramiro Gonzalez <br>C/O Chicago AIDS Ride 5 <br>1729 W. Melrose <br> Chicago, IL.<br>60657-1003</font><br>Please make the check payable to<br> Chicago AIDS Ride 5. <br>Once again, Thank you for your support.</center></font></b></i> <br> <center><FORM ACTION="/cgi-bin/script_library/form_handler_mail" METHOD=POST> First Name<br> <INPUT TYPE="text" VALUE="" NAME="first_name"><br> Last Name<br> <INPUT TYPE="text" VALUE="" NAME="last_name"><br> Street Address<br> <INPUT TYPE="text" VALUE="" NAME="address"><br> City<br> <INPUT TYPE="text" VALUE="" NAME="city"><br> State<br> <INPUT TYPE="text" VALUE="" NAME="state" maxlength="2" size="1"><br> Zip<br> <INPUT TYPE="text" VALUE="" NAME="zip" maxlength="10" size="10"><BR> Country<br> <INPUT TYPE="text" VALUE="" NAME="country"><br> E-mail address<br> <INPUT TYPE="text" VALUE="" NAME="email"><br> Amount of Pledge<br> <INPUT TYPE="text" VALUE="" NAME="pledge" maxlength="9" size="9"><br> <INPUT TYPE="hidden" NAME="end_display" VALUE="http://www.angelfire.com/il2/comp63"> <INPUT TYPE="hidden" NAME="required" VALUE="first_name, last_name, address, city, state, zip, country, pledge"> <INPUT TYPE="hidden" NAME="order" VALUE="first_name, last_name, address, city, state, zip, country, email, pledge"> <INPUT TYPE="hidden" NAME="email_to" VALUE="comp63@aol.com"> <br> <INPUT TYPE="submit" VALUE="Submit"> </FORM></center>