Web Order Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=100 BGCOLOR="#CCCCFF" TEXT="#080000" bgproperties="fixed" background="25600640egdysm.jpg"> <div> <FONT SIZE="5" COLOR="#000066" FACE="Calligrapher" ><B>BRIGHTER LEARNING</B></FONT><FONT SIZE="5" COLOR="#000099" FACE="Arial" ><B> </B></FONT><FONT SIZE="1" COLOR="#000099" FACE="Arial" ><B>  </B><B>  </B></FONT><B>|   </B><B>  </B><A HREF="index.htm" TARGET="_top" TITLE="BRIGHTER LEARNING"><U><B>home</B></U></A></div> <div> <B>Web Order Form</B><B>   |   </B><A HREF="id23.htm" TARGET="_top" TITLE="Printable Order Form"><U><B>Printable Order Form</B></U></A><B>   |   </B><A HREF="id26.htm" TARGET="_top" TITLE="Printable Gift Certificate"><U><B>Printable Gift Certificate</B></U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=50 BGCOLOR="#0000BF" TEXT="#F7F7FF"> <bR> </td> <td valign="top" height=380 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <div> <I>Web Order Form</I></div> <bR> <div>  <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>If you are paying through PayPal</title> </head> <body> <ul> <li>If you are paying through PayPal, please proceed to check-out and PayPal will redirect you back to this page.</li> <li>If you are mailing a check to Brighter Learning, you may submit this form and then mail in a check (If you would like Brighter Learning to total your order, check the appropriate box toward the bottom of this form).</li> </ul> <form action="http://pub29.bravenet.com/emailfwd/senddata.php" method="POST" enctype="multipart/form-data"> <input type="hidden" name="cpv" value="2"><input type="hidden" name="usernum" value="2432790485"> <p> Purchaser Name    <input type="text" name="Purchaser_Name" size="25">     Purchaser Email or Phone   <input type="text" name="Purchaser_Contact" size="30"></p> <p><font color="#990099"><b>BOOK LANGUAGE and TITLE (Language the text will be written in and the title of the selected book).</b></font></p> <p style="line-height: 200%; margin-top: 0; margin-bottom: 0"><input type="checkbox" name="English_Text" value="Yes"> English Text / Title <select size="1" name="English_Title"> <option selected>None</option> <option>My Baby Book</option> <option>Flinstonges</option> <option>Spider-Man</option> <option>Looney Tunes</option> <option>Where's Waldo</option> <option>Batman</option> <option>My Day on Sesame Street</option> <option>Scooby-Doo</option> <option>Sesame Street: Let's Count</option> <option>Sesame Street: ABC and Me</option> <option>SPY kids</option> <option>Superman/Wonder Women</option> <option>X-Men</option> <option>African-American Heroes</option> <option>African-American Santa</option> <option>Baby Jesus</option> <option>Ballerina Princess</option> <option>Beauty and the Beast</option> <option>Circus Star:Birthday at the Circus</option> <option>Circus Star:Circus Party</option> <option>Dinosaur Land</option> <option>Farm Animals</option> <option>Football Star</option> <option>G-o-o-oal: A Soccer Story</option> <option>Jesus the Provider</option> <option>Jewish Holidays</option> <option>Kwanzaa</option> <option>Little Mermaid</option> <option>Mother Goose</option> <option>Ninja Adventure</option> <option>Noah's Ark</option> <option>Caucasian Santa</option> <option>School is Fun</option> <option>Sports Superstar</option> <option>Teddy Bear Land</option> <option>Three Little Pigs</option> <option>When I Grow Up</option> <option>Letter from Santa: African-American</option> <option>Letter from Santa:Caucasian</option> <option>Letter from Easter Bunny</option> </select>  </p> <p style="line-height: 100%; margin-top: 0; margin-bottom: 0"><input type="checkbox" name="Spanish_Text" value="Yes">  Spanish Text / Title  <select size="1" name="Spanish_Title"> <option selected>None</option> <option>My Baby Book</option> <option>Flinstonges</option> <option>Spider-Man</option> <option>Where's Waldo</option> <option>Batman</option> <option>My Day on Sesame Street</option> <option>Sesame Street: Let's Count</option> <option>Superman/Wonder Women</option> <option>X-Men</option> <option>Baby Jesus</option> <option>Beauty and the Beast</option> <option>Circus Star:Birthday at the Circus</option> <option>Circus Star:Circus Party</option> <option>Dinosaur Land</option> <option>Farm Animals</option> <option>G-o-o-oal: A Soccer Story</option> <option>Jesus the Provider</option> <option>Jewish Holidays</option> <option>Little Mermaid</option> <option>Ninja Adventure</option> <option>Noah's Ark</option> <option>Caucasian Santa</option> <option>School is Fun</option> <option>Sports Superstar</option> <option>Teddy Bear Land</option> <option>Three Little Pigs</option> <option>When I Grow Up</option> <option>Letter from Santa:Caucasian</option> <option>Letter from Easter Bunny</option> </select></p> <ul> <li><b>First Name</b>: <input type="text" name="First_Name" size="20">   Middle Name (Optional):  <input type="text" name="Middle_Name" size="20"></li> <li>Nickname (Optional: after 1st page, program uses nickname throughout book): <input type="text" name="Nickname" size="20"></li> <li><b>Last Name</b>:  <input type="text" name="Last_Name" size="20"></li> <li><b>Gender</b>:  <input type="checkbox" name="Gender_Female" value="Yes"> Female     <input type="checkbox" name="Gender_Male" value="Yes">Male                                  Age (optional):  <input type="text" name="Age" size="10"></li> <li> <p style="line-height: 150%"><b>Hometown and State</b> (ex., Woodland Park, Colorado):  <input type="text" name="Hometown" size="35"></li> <li><b>Three Friends, Relatives, Pets,</b> etc. that you want listed in the story (maximum combined length including commas and spaces is 55). <ol> <li><input type="text" name="Friend_1" size="20"></li> <li><input type="text" name="Friend_2" size="20"></li> <li><input type="text" name="Friend_3" size="20"></li> </ol> </li> <li><b>Message</b> (ex, With Love! or Happy Birthday):  <input type="text" name="Message" size="35"></li> <li><b>This Book is From</b>:  <input type="text" name="From" size="35"></li> <li>Date (optional: ex May 2004 or May 15, 2004):  <input type="text" name="Date" size="35"></li> </ul> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>If you are ordering My Baby Book, Football Star, G-o-o-oal, or School is Fun,</b></p> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>please continue below in the appropriate area.</b></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"> </p> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b><font color="#990099">Additional Information for <i>My Baby Book</i> ONLY</font></b></p> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"> </p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>VERSION:  <input type="checkbox" name="Version_2Parent" value="Yes">Two-Parent        <input type="checkbox" name="Version_Mother" value="Yes">Mother Only      <input type="checkbox" name="Version_Father" value="Yes">Father Only</b></p> <ul> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Date of Birth:   Month <select size="1" name="Birth_Month"> <option selected>None</option> <option>January</option> <option>February</option> <option>March</option> <option>April</option> <option>May</option> <option>June</option> <option>July</option> <option>August</option> <option>September</option> <option>October</option> <option>November</option> <option>December</option> </select>      Day <select size="1" name="Birth_Day"> <option selected>None</option> <option>1</option> <option>2</option> <option>3</option> <option>4</option> <option>5</option> <option>6</option> <option>7</option> <option>8</option> <option>9</option> <option>10</option> <option>11</option> <option>12</option> <option>13</option> <option>14</option> <option>15</option> <option>16</option> <option>17</option> <option>18</option> <option>19</option> <option>20</option> <option>21</option> <option>22</option> <option>23</option> <option>24</option> <option>25</option> <option>26</option> <option>27</option> <option>28</option> <option>29</option> <option>30</option> <option>31</option> </select>    Year  <input type="text" name="Birth_Year" size="6"></li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Time of Birth:  <input type="text" name="Birth_Time" size="5">     <input type="checkbox" name="Time_AM" value="Yes">AM    <input type="checkbox" name="Time_PM" value="Yes">PM</li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Baby's Weight:  Pounds <input type="text" name="Birth_Pounds" size="2">   Ounces  <input type="text" name="Birth_Ounces" size="2"></li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Baby's Length (Inches):  <input type="text" name="Birth_Length" size="10"></li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Delivered By:  <input type="text" name="Birth_Delivered" size="35">   Hospital:  <input type="text" name="Birth_Hospital" size="40"></li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Mom's First Name (If Applicable): <input type="text" name="Birth_Mom" size="30">  </li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Father's First Name (If Applicable): <input type="text" name="Birth_Father" size="30"></li> </ul> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><font color="#990099"><b>Additional Information for <i>Football Star </i>/ <i>G-o-o-oal Soccer</i> (optional)</b></font></p> <ul> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Favorite Players:<b><font color="#990099">  </font></b><input type="text" name="Favorite_Player" size="32"></li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Winning Team: <input type="text" name="Winning_Team" size="35">   Losing Team: <input type="text" name="Losing_Team" size="35"></li> </ul> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><font color="#990099"><b>Additional Information for School is Fun ONLY (optional)</b></font></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"> </p> <ul> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Teacher's Name: <input type="text" name="Teacher_Name" size="35">   School Name:<input type="text" name="School_Name" size="35"></li> </ul> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>PAYMENT:    <input type="checkbox" name="Payment_Paypal" value="Yes">PayPal</b></p> <blockquote> <blockquote> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">     <input type="checkbox" name="Payment_Check" value="Yes"><b>Mailing Check/Money Order </b>(mail to: Brighter Learning, 181 Honey Hill Ln, Woodland</p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">             Park, CO  80863)</p> <blockquote> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">             <input type="checkbox" name="Email_Total" value="Yes">Check if you would like your total e-mailed to you.</p> </blockquote> <p align="left" style="line-height: 100%; text-indent: 0; margin-top: 0; margin-bottom: 0">     <input type="checkbox" name="Certificate" value="Yes"><b>Redeeming Gift Certificate:</b>   Amount <input type="text" name="Certificate_Amount" size="10">    Code  <input type="text" name="Certificate_Code" size="18"></p> </blockquote> </blockquote> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b><font color="#990099">Would you like to be on our Mailing List?    <input type="checkbox" name="Maillist_Yes" value="Yes"></font>Yes  How would you like to receive Specials  <select size="1" name="Maillist_Type"> <option selected>(Blank)</option> <option>Via E-mail</option> <option>Via Postal Mail</option> <option>Both</option> </select> </b></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>                                                                         <input type="checkbox" name="Maillist_No" value="No">No     <input type="checkbox" name="Maillist_On" value="ON">Already on List</b></p> <blockquote> <ul> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>Information is NEVER sold, traded or given to another party.</b></li> </ul> </blockquote> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>SHIPPING ADDRESS:</b></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>                                       <textarea rows="4" name="Shipping_Address" cols="40"></textarea></b></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"> </p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>Comments:</b></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b>                     <textarea rows="4" name="Comments" cols="40"></textarea></b></p> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0"> </p> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><b><u>PLEASE VERIFY ALL INFORMATION ON FORM BEFORE SUBMITTING.</u></b></p> <blockquote> <ul> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">If Customer makes a mistake, we will reprint at a Lesser Cost.</li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">Satisfaction Guaranteed - Full Refund less S/H if returned within 30 days.</li> <li> <p align="left" style="line-height: 100%; margin-top: 0; margin-bottom: 0">FREE Photo Frame Sticker with each Book Purchase.</li> </ul> <p align="center" style="line-height: 100%; margin-top: 0; margin-bottom: 0"><input type="submit" value="Submit" name="Submit">             <input type="reset" value="Reset" name="Reset"></p> </blockquote> </form> </body> </html>  </div> </td> </tr></table></body>