Order Form ~

charset="UTF-8">
 <div>
  <input type="hidden" name="acctid" id="acctid" value="zr87lbtbhy678ymn" />
  <input type="hidden" name="formid" id="formid" value="872065" />
  <input type="hidden" name="required_vars" id="required_vars" value="name,email" />
 </div>
 <table cellspacing="5" cellpadding="5" border="0">
  <tr>
   <td valign="top">
    <strong>Name:</strong>
   </td>
   <td valign="top">
    <input type="text" name="name" id="name" size="40" value="" />
  
   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>Email Address:</strong>
   </td>
   <td valign="top">
    <input type="text" name="email" id="email" size="40" value="" />
  
   </td>
  </tr>
  <tr>
   <td colspan="2" align="center">
    <input type="submit" value=" Submit Form " />
   </td>
  </tr>
 </table>
</form>
<br><center><font face="Arial, Helvetica" size="1"><b>
Form provided by <a href="http://www.freedback.com%22%3efreedback%3c/a>.
</b></font></center>
<!-- End Freedback Form -->