<HTML>
<HEAD>
<title>Respone-O-Matic Form</title>
</head>
<body bgcolor="#FFFFFF">
<CENTER>
<form action="http://www.response-o-matic.com/cgi-bin/rom.pl" method="post">
<A HREF="http://www.123banners.com/cgi-bin/banners/members/com2/X30717/gotoad.pl"
target="_top">
<IMG SRC="http://www.123banners.com/cgi-bin/banners/getad?m_no=X30717&page=1"
WIDTH=440 HEIGHT=40 ISMAP></A>
<BR>
<A HREF="http://www.geocities.com/linkchannel/">
<FONT SIZE=2>LinkChannel</FONT></A>
</CENTER>
<p>
<center>
<a href="http://media.exchange-it.com/click.go?B121018'1"
target="_top">
<img src="http://media.exchange-it.com/image.go?B121018=1"
width=468 height=60 border=1 alt="click to Visit"></a>
</center>
<p>
<h1><center> </center></h1>
<h1><center><font color="#000000">Thanks for visiting my site!</font></center></h1>
<h3><center>
<input type="hidden" name="your_email_address" value="Isikan alamat e-mail anda di sini !">
<input type="hidden" name="your_name" value="Isikan nama anda di sini !">
<input type="hidden" name="email_subject_line" value="Isikan e-mail subjek anda di sini !">
<input type="hidden" name="required_fields" value="your_email_address">
<input type="hidden" name="thank_you_title" value="Thank you">
<input type="hidden" name="return_link_url" value="Isikan alamat website anda di sini !">
<input type="hidden" name="return_link_name" value="back">
<input type="hidden" name="background_color" value="#FFFFFF">
<input type="hidden" name="text_color" value="#0000FF">
<input type="hidden" name="link_color" value="#FF0000">
<input type="hidden" name="visited_link_color" value="#0000FF">
<input type="hidden" name="active_link_color" value="#FF0000">
</center></h3>
<h3><center>Your comments are appreciated!</center></h3>
<p><center>Just complete this form. Click on Submit when ready to send.</center></p>
<h4> </h4>
<blockquote><p><table border=0 cellspacing=0>
<tr>
<td width=116>
<h3>Your name:</h3>
</td><td>
<h4><input type="text" name="visitor_name" value="" size=50>
</h4>
</td></tr>
<tr>
<td width=116>
<h3>Email address:</h3>
</td><td>
<h4><input type="text" name="visitor_email_address" value="" size=50></h4>
</td></tr>
<tr>
<td width=116>
<h3>Your web address :</h3>
</td><td>
<h4><input type="text" name="visitor web address" value="" size=50></h4>
</td></tr>
<tr>
<td width=116>
<h3>Web title:</h3>
</td><td>
<h4><input type="text" name="Web title" value="" size=50></h4>
</td></tr>
</table>
<h3>Where do you want to go today?</h3>
<p><input type="radio" name="Where to?" value="I don't know">I don't know<br>
<input type="radio" name="Where to?" value="America">America<br>
<input type="radio" name="Where to?" value="France" checked>France<br>
<input type="radio" name="Where to?" value="Indonesia">Indonesia
</p>
<p> </p>
<h3>What's you hobby?</h3><p>
<input type="checkbox" name="Movies I like" value="shopping">shopping<br>
<input type="checkbox" name="Movies I like" value="sport">sport<br>
<input type="checkbox" name="Movies I like" value="gaming" checked>gaming<br>
<input type="checkbox" name="Movies I like" value="reading">reading
</p></blockquote>
<p> </p>
<blockquote><h3>How many salesmen does it take to change a light bulb?</h3>
<p><select name="name">
<option selected>Who cares?
<option>I hate this joke.
<option>One
<option>Two
<option>Three
<option>Only one. But today, and today only.
</select></p></blockquote>
<p> </P>
<blockquote><h3>Any comments?</h3>
<p><textarea name="Comment" rows=5 cols=50></textarea></p>
</blockquote>
<h4> </h4>
<blockquote><p><input type="submit" name="Submit" value="Submit">
<input type="reset" value="Reset"></p></blockquote>
<p> </p>
</form>
</body>
</html>
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