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<CENTER><H1>CUSTOMER ORDER FORM</H1>
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As you fill out the form below, appropriate
calculations will be made. Please take care to check over the form when
you are complete, so as to avoid any mistakes. Thank you!
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<H3>Shipping Address</H3>
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<TABLE border=0 cellpadding=2>
<TR><TD align=RIGHT>Name:</TD>
<TD><INPUT TYPE=TEXT NAME="username" VALUE="MALINI"size=45>
</TD></TR>
<TR><TD align=RIGHT>Address:</TD>
<TD><INPUT TYPE=TEXT NAME="Address" VALUE="1200 XYZ AVE" size=60><BR><INPUT NAME="Address"
size=60></TD></TR>
<TR><TD align=RIGHT>City:</TD>
<TD><INPUT TYPE=TEXT NAME="city" VALUE="SANTA CLARA" size=25>
State: <INPUT TYPE=TEXT NAME="state" VALUE="CA" size=2>
Zip Code: <INPUT TYPE=TEXT NAME="zip" VALUE="95050" size=10></TD></TR>
<TR><TD ALIGN=right>Day Phone:</TD>
<TD><INPUT TYPE=TEXT NAME="phone" VALUE="(123)456 7890" SIZE=14>
Fax: <INPUT TYPE=TEXT NAME="fax" VALUE="(123)456 7890" SIZE=14>
Country: <INPUT TYPE=TEXT NAME="USA" SIZE=14 ></TD></TR>
<TR><TD ALIGN=right>E-Mail:</TD>
<TD><INPUT TYPE=TEXT NAME="email" VALUE="vmalini@yahoo.com" SIZE=60></TD></TR>
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<HR><H3>Method of Payment</H3>
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this credit card for payment:
<DD><INPUT TYPE="RADIO" NAME="visa" VALUE="VISA" CHECKED>Visa
<INPUT TYPE="RADIO" NAME="mast" VALUE="MAST">Master Card
<DD>Card Number <INPUT TYPE=TEXT NAME="cardno" VALUE="123456789" size=20>
Expiration Date <INPUT TYPE=TEXT NAME="expdate" VALUE="07-01-99" size=8></DL>
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