<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>