Customer Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006666" TEXT="#080000" bgproperties="fixed" background="4b3a45a3.jpg"> <div> <B><IMG SRC="53a7b1e0.png" border=0 width="123" height="30" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B> <OBJECT classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/ flash/swflash.cab#version=5,0,0,0" width="464" height="69"> <PARAM name="movie" value="forefrontfollowstores.swf"> <PARAM NAME="wmode" VALUE="transparent"> <PARAM name="quality" value="high"> <PARAM name="menu" value="true"> <EMBED src="forefrontfollowstores.swf"WMODE"transparent"quality="high" menu="true" pluginspage="http://www.macromedia.com/shockwave/download/index.cgi?P1_Prod_Version=ShockwaveFlash" type="application/x-shockwave-flash" width="464" height="69"> </EMBED> </OBJECT>  </B></FONT></div> </td> </tr><tr> <td valign="top" width=200 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <A HREF="mailto:sales@birdstores.com" TARGET="_top" TITLE="mailto:sales@birdstores.com"><I><U>Salesperson@birdstores.com</U></I></A></div> <bR> </td> <td valign="top" height=390 width="100%" BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <div> Customer Form<FONT SIZE="4" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG SRC="43c184b0.gif" border=0 width="280" height="75" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><FONT SIZE="6" COLOR="#000000" FACE="Algerian" > <SCRIPT language="JavaScript">  </SCRIPT>  </FONT></div> <bR> <bR> <div>  <FORM METHOD=post ACTION="http://birdstores.com/cgi-sys/FormMail.cgi"> <input type=hidden name="recipient" value="info@birdstores.com"> OR <input type=hidden name="recipient" value="Cherane@birdstores.com"> <input type=hidden name="required" value="info@birdstores.com"> <input type=hidden name="subject" value="Contact & Questions"> <input type=hidden name="required" value="name,email,state,phone"> <input type=hidden name="env_report" value="REMOTE_HOST,HTTP_USER_AGENT"> <input type=hidden name="redirect" value="http://www.birdstores.com/id81_t.htm"> Store of Interest - Subject <INPUT TYPE="text"Name="realname" size=30 MAX=30> </script> </tr> </table> </div> <div align="left"> <tab> </ </div> <p> <br> </p> </td><td valign="top" width="24"><font size="4"><font color="#006460"></td><td valign="top"> <p><br>Thank you for taking the time to browse through our bird stores.. This site was developed for you</p> <p>If you would like more information on Aviculture Equipment, Facility Products or Any BirdStores.com Items, please contact <a href="mailto:CustomerCare@birdstores.com">CustomerCare@birdstores.com</a> or use our mail form below.</p>  <input TYPE="hidden" NAME="BIRDSTORES" VALUE="0"> <p>Please provide information in order to better serve you.</p> <div align="center"> <center> <table border="0" cellpadding="3" cellspacing="0" width="90%"> <tr> <td>Your Name</td> <td><INPUT name="Name" value="" size="35"><BR> </td> </tr> <tr> <td>Address 1</td> <td><input type="text" name="Address_1" size="35"></td> </tr> <tr> <td>Address 2</td> <td><input type="text" name="Address_2" size="35"></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tr> <td>City</td> <td><input type="text" name="City" size="14"></td> <td>State</td> <td><input type="text" name="State" size="5"></td> <td>Zip</td> <td><input type="text" name="Zip" size="9"></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tr> <td>Email</td><td><input type="text" name="Email" size="30"></td> </tr> <tr> <td>Phone</td><td><input type="text" name="Phone" size="30"></td> </tr> <tr> <td>How Can I Assist You?:<br> <font size="2"><font color="#006460"> Please hold CTRL Key to make multiple selections.</font><br>If a general inquiry, choose other.</font></td> <td><select size="8" name="Equipment & Products" multiple> <option>Incubator & Brooder,</option> <option>Bird Food,</option> <option>Cage Cleaner</option> <option>Cages & Play Stands,</option> <option>Nursery Equipment & Supplies,</option> <option>Bird Food</option> <option>Toys</option> <option>Disinfectant/option> <option>Books</option> <option>Other</option> </select></td> </tr> <tr> <td>Comments.</td><td><textarea rows="8" name="General_Comments" cols="27"></textarea></td> </tr> </table> </center> </div> <p align="center"><input name="ordernow" type="submit" value="Submit Form"> <input name="reset" type="reset" value="Clear Form"> <input type="button" value="Questions" onClick="parent.location='mailto:mail@birdstores.com'" name="button"><br><br>  </div> <bR> <bR> <div>                                          <B> </B><FONT SIZE="3" COLOR="#CC00CC" FACE="AntigoniBd" ><B>  </B></FONT><FONT SIZE="3" COLOR="#990000" FACE="AntigoniBd" ><B>Cherane Pefley-Heavenly Aviary</B></FONT></div> <DIV ALIGN="LEFT"></DIV> <div> <B>Vero Beach, FL., 32963 </B></div> <bR> <div> <B>Email: info</B><A HREF="mailto:Clerk@birdstores.com" TARGET="_top" TITLE="mailto:Clerk@birdstores.com"><B>@birdstores.com</B></A></div> <bR> <div>                                                     </div> <div> <B>                                                 </B><FONT SIZE="3" COLOR="#000000" FACE="Algerian" ><B> </B></FONT><FONT SIZE="3" COLOR="#000000" FACE="Antigoni Light" >  </FONT>  </div> <div> <A HREF="germicidal.htm" TARGET="_top" TITLE="GERMICIDAL"><B><U><IMG BORDER="0" SRC="Symb075c00b7011866660000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">GERMICIDAL</U></B></A></div> <div> <A HREF="id15.htm" TARGET="_top" TITLE="Equipment"><B><U><IMG BORDER="0" SRC="Symb075c00b7011866660000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Equipment</U></B></A></div> <div> <A HREF="id2.htm" TARGET="_top" TITLE="Bird Food"><B><U><IMG BORDER="0" SRC="Symb075c00b7011866660000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bird Food</U></B></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="_"><B><U><IMG BORDER="0" SRC="Symb075c00b7011866660000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">--Type Title Here--</U></B></A></div> <div> <A HREF="id86.htm" TARGET="_top" TITLE="AlphaZyme Plus"><B><U><IMG BORDER="0" SRC="Symb075c00b7011866660000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AlphaZyme Plus</U></B></A></div> <div> <A HREF="id87.htm" TARGET="_top" TITLE="Broad Spectrum Germicidal"><B><U><IMG BORDER="0" SRC="Symb075c00b7011866660000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Broad Spectrum Germicidal</U></B></A></div> <bR> <bR> <div> Design and built by: Cherane Pefley Copyright © December 2, 2002.   All rights reserved.</div> </td> </tr></table></body>