<p align="center"><form method="get" target="_blank"> <strong>Name:<strong/> <input type="Text" name="Name" value="Your Name" maxlength="50" size="25"> <br> <strong>Company Name:<strong/>

<input type="Text" name="Companyname" value="Your CompanyName" maxlength="50" si ze="25"> <br> <strong>E-Mail Address:<strong/> <input type="text" name="E-Mail Address" value="Your E-Mail" maxlength="50" size "25"> <br> <b>I Need:<b/> <input id="Sales" type="checkbox" value="Sales" /> <label for="Sales">Sales</label> <input id="Supplies" type="checkbox" value="Supplies" /> <label for="Supplies">Supplies</label> <input id="Service" type="checkbox" value="Service" /> <label for="Service">Service</label> <br> <strong>A Brief Desciption:<strong/> <input type="Text" name="Comments" value="Comments" maxlength="150" size="30"> <input type="Button" name="Submit" value="Submit"> </form><p/>