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<table>
<form action="http://oi.vresp.com/" method="post">
<input type=hidden name=fid value="278188e017">
<tr><td>Email Address:</td><td><input type=TEXT name="email_address"></td></tr>
<tr><td>First Name:</td><td><input type=TEXT name="first_name"></td></tr>
<tr><td>Last Name:</td><td><input type=TEXT name="last_name"></td></tr>
<tr><td>What is your favorite color of amber?</td><td><input type=TEXT name="Favorite_color_of_amber"></td></tr>
<tr><td>What month is your birthday in?</td><td><input type=TEXT name="Birth_Month"></td></tr>
<tr><td colspan=2><input type=checkbox value=1 name=optin>I want to receive mailings from Andzia's Amber Jewelry</td></tr>
<tr><td colspan=2><input type=hidden name=form_submitted value=1>
<input hspace=5 type=image border=0 src="http://oi.vresp.com/join_now.gif" name="form_submitted" value="submit"></td></tr></form>
</table>
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