Info request form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=105 BGCOLOR="#006699" TEXT="#080000" background="05028691erlcgo.png"> <div> <B> </B><FONT SIZE="6" COLOR="#FFCC66" FACE="Arial" ><B> </B></FONT><FONT SIZE="6" COLOR="#FFCC66" FACE="Arial" ><B>Columbia Electronics International, Inc.</B></FONT></div> <bR> <div> <B>3720 Groves Place  </B><FONT SIZE="2" COLOR="#FFFFCC" FACE="WP IconicSymbolsA" ><B>Ž</B></FONT><B>  PO Box 960 </B><FONT SIZE="2" COLOR="#FFFFCC" FACE="WP IconicSymbolsA" ><B>Ž</B></FONT><B>  Somis  </B><FONT SIZE="2" COLOR="#FFFFCC" FACE="WP IconicSymbolsA" ><B>Ž </B></FONT><B>California  93066-0960  </B><FONT SIZE="2" COLOR="#FFFFCC" FACE="WP IconicSymbolsA" ><B>Ž</B></FONT><B>  Phone  805-386-2312  </B><FONT SIZE="2" COLOR="#FFFFCC" FACE="WP IconicSymbolsA" ><B>Ž</B></FONT><B>  FAX  805-386-2314</B></div> <div> <B>  </B><B>   </B></div> <div> </div> </td> </tr><tr> <td valign="top" height=375 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I><B>Information Request form</B></I></div> <bR> <bR> <div> <I><B>     </B></I></div> <div> <I><B> <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="Date,First Name,LastName,Title or Dept,Company,Address1,Address2,City,State or provence,Zip or Postal Code,Phone,Email,Fax,Item of interest,Advise Cost to ship & Qty.,Delivery requirement:,Comments"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for information. We will respond ASAP. "><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="We will respond very soon."><input type="hidden" name="tlx_EmailTo" value="sales@columbiaelectronics.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Date:<br> <input type="text" name="Date" size="30" maxlength="30"></td> </tr> <tr> <td align="left">First Name:<br> <input type="text" name="First Name" size="50" maxlength="100"></td> </tr> <tr> <td align="left">Last Name:<br> <input type="text" name="LastName" size="50" maxlength="100"></td> </tr> <tr> <td align="left">Title and/or Dept.:<br> <input type="text" name="Title or Dept" size="50" maxlength="100"></td> </tr> <tr> <td align="left">Company:<br> <input type="text" name="Company" size="100" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="100" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 2:<br> <input type="text" name="Address2" size="100" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="75" maxlength="100"></td> </tr> <tr> <td align="left">State or Provence:<br> <input type="text" name="State or provence" size="50" maxlength="100"></td> </tr> <tr> <td align="left">Zip or Postal Code:<br> <input type="text" name="Zip or Postal Code" size="30" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number & Ext. No.:<br> <input type="text" name="Phone" size="25" maxlength="25"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="50" maxlength="100"></td> </tr> <tr> <td align="left">Fax Number:<br> <input type="text" name="Fax" size="20" maxlength="20"></td> </tr> <tr> <td align="left">Item or items of Interest:<br> <input type="text" name="Item of interest" size="150" maxlength="150"></td> </tr> <tr> <td align="left">Advise Cost to ship for Qty of::<br> <input type="text" name="Advise Cost to ship & Qty." size="150" maxlength="150"></td> </tr> <tr> <td align="left">Delivery requirement::<br> <input type="text" name="Delivery requirement:" size="50" maxlength="50"></td> </tr> <tr> <td align="left">Comments:<br> <textarea name="Comments" rows="40" cols="150"></textarea></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </B></I></div> <bR> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="mbia Electronics International, Inc."><U><B>Home</B></U></A></div> </td> </tr></table></body>