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<table width=”250″ border=”0″ cellspacing=”20″ bgcolor=”#EEEEEE” STYLE=”font-size: 12px;”>
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<td><font color=”#000000″>Your Name:</font></td><td><input type=”text” name=”name” size=”14″></td></tr>
<tr>
<td><font color=”#000000″>Your E-Mail:</font></td><td><input type=”text” name=”email” size=”14″></td></tr>
<tr><td><font color=#000000>Phone:</font></td><td><input type=”text” name=”phone” size=”14″></td></tr>
<tr><td><font color=#000000>Address:</font></td><td><input type=”text” name=”address” size=”14″></td></tr>
<tr><td><font color=#000000>City:</font></td><td><input type=”text” name=”city” size=”14″></td></tr>
<tr><td><font color=#000000>State:</font></td><td><input type=”text” name=”state” size=”14″></td></tr>
<tr><td><font color=#000000>Zip:</font></td><td><input type=”text” name=”zip” size=”14″></td></tr>
<tr><td><font color=#000000>Country:</font></td><td><input type=”text” name=”country” size=”14″></td></tr>
<tr><td><font color=#000000>Email
:</font></td><td><input type=”text” name=”email” size=”14″></td></tr><tr><td><font color=#000000>Date of Birth:</font></td><td><input type=”text” name=”date-of-birth” size=”14″></td></tr>
<tr></td><td><td align=”center”>
<input type=”submit” STYLE=”background-color:CCCCCC; ; color:000000″ value=”Sign Up!”></td></tr>
<tr><td colspan=”2″ align=”center”><a STYLE=”text-decoration:none” href=”http://allinoneprofits.com/”><font color=”#000000″>powered by AIOP</font></a>
<br><font color=”#000000″>We respect your privacy</font></td></tr>
</table>
<input type=”hidden” name=”user_id” value=”9838″ />
<input type=”hidden” name=”return_url” value=”getpaymentminsite.wordpress.com”>
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