Order

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=50 BGCOLOR="#CCCCFF" TEXT="#080000" bgproperties="fixed" background="04000660egdysm.jpg"> <div> <FONT SIZE="5" COLOR="#000066" FACE="Arial" ><B>--Type Title Here--</B></FONT><FONT SIZE="5" COLOR="#000099" FACE="Arial" ><B> </B></FONT><B> </B></div> <div> </div> </td> </tr><tr> <td valign="top" width=150 BGCOLOR="#0000BF" TEXT="#F7F7FF"> <bR> </td> <td valign="top" height=430 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Order</I></div> <div>  <form action="http://formmail.trellix.com/servlets/TlxMailer" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,LastName,Email,Company,Address1,City,State,Zip,Phone,Item"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your Order"><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="Order"><input type="hidden" name="tlx_EmailTo" value="RDaiuto@aol.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">First Name:<br> <input type="text" name="FirstName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Last Name:<br> <input type="text" name="LastName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Company:<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">State:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Zip:<br> <input type="text" name="Zip" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Items & Item #'s:<br> <textarea name="Item" rows="5" cols="30"></textarea></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </div> </td> </tr></table></body>