Long Ridge Writers Group - Writing for Adults

<body> <?php include '/home/frank/lib/php/html.inc'?> <?php include '/home/frank/lib/php/counter.inc'?> <?php if ($si_count == "") { $si_count = counter('../counters/si.counter', 1); } ?> <div align="center"> <table border="0" cellpadding="0" cellspacing="0" width="500"> <tr> <td> <p align="center"> <img border="0" src="images/Send-Me.gif"><td width="15%"><a href="" onclick="Pcertify();return false;"><img src="images/PrivacySeal1.gif" alt="BBBOnLine Privacy Seal" WIDTH=85 HEIGHT=130 BORDER=0></a></td> </tr> </table> </div> <p><font face="Georgia" style="font-size: 11.5pt">Please send me your free Writing Test and 32-page brochure describing your program <i>Breaking into Print</i>. I understand I</font><span style="font-size: 11.5pt; font-family: Georgia">’</span><font face="Georgia" style="font-size: 11.5pt">m under no obligation whatever.</font></p> <p><font face="Georgia" style="font-size: 11.5pt">Here is my information: (*indicates required fields)</font></p> <table border="0" cellpadding="2" cellspacing="1" width="95%"> <tr><script Language="JavaScript" Type="text/javascript"></script> <form action="Confirm_Info.htm" method="POST" onsubmit="return FrontPage_Form1_Validator(this)" name="FrontPage_Form1" language="JavaScript"> <pre><font face="Tahoma"> <font color="#000080">*Name: </font></font><select name="Title" size="1"> <?php html_options(array('Ms.', 'Mrs.', 'Mr.', 'Miss'), $_REQUEST['Title'], 'Mr.', FALSE); ?> </select><input type="text" size="15" name="First_Name" value="<?=htmlspecialchars($_REQUEST['First_Name'])?>"><input type="text" size="25" name="Last_Name1" value="<?=$_REQUEST['Last_Name1']?>"> <font face="Tahoma" style="font-size: 9pt"> <font color="#000080">First Name Last Name</font></font></pre><pre><font face="Tahoma" color="#000080"> *Street Address: </font><input type="text" size="40" name="Street_Address" value="<?=$_REQUEST['Street_Address']?>"></pre><pre><font face="Tahoma">     <font color="#000080"> Apartment: </font></font><input type="text" size="40" name="Apartment" value="<?=$_REQUEST['Apartment']?>"></pre><pre><font face="Tahoma" color="#000080">      *City: </font><input type="text" size="40" name="City" value="<?=$_REQUEST['City']?>"></pre><table border="0" width="100%"> <tr> <td width="187"><font face="Tahoma" size="2" color="#000080">*State/ Province/ Other: </font>  <select name="State" size="1" onchange="countryOrStateChanged(this); return true;"><?php html_options(array('Please Select', '----USA----', 'AA', 'AE', 'AL', 'AK', 'AP', 'AS', 'AZ', 'AR', 'CA', 'CO', 'CT', 'DE', 'DC', 'FM', 'FL', 'GA', 'GU', 'HI', 'ID', 'IL', 'IN', 'IA', 'KS', 'KY', 'LA', 'ME', 'MH', 'MD', 'MA', 'MI', 'MN', 'MS', 'MO', 'MT', 'NE', 'NV', 'NH', 'NJ', 'NM', 'NY', 'NC', 'ND', 'MP', 'OH', 'OK', 'OR', 'PW', 'PA', 'PR', 'RI', 'SC', 'SD', 'TN', 'TX', 'UT', 'VT', 'VI', 'VA', 'WA', 'WV', 'WI', 'WY', '---CANADA---', 'AB', 'BC', 'MB', 'NB', 'NL', 'NT', 'NS', 'NU', 'ON', 'PE', 'QC', 'SK', 'YT', 'OTHER COUNTRY'), $_REQUEST['State'], 'Please Select', FALSE); ?> </select>  </td> <td><font face="Tahoma" size="2" color="#000080">*Zip/Postal Code: </font>  <input type="text" size="24" name="Zip" value="<?=$_REQUEST['Zip']?>"></td></tr></table><table border="0" width="100%"> <tr> <td width="188"><font face="Tahoma" size="2" color="#000080">               *Country: </font> <select name="Country" size="1" onchange="countryOrStateChanged(this); return true;"><?php html_options(array('USA', 'Canada','Other - Specify'), $_REQUEST['Country'], 'USA - Canada', FALSE); ?> </select>  </td> <td><font face="Tahoma" size="2" color="#000080">Other Country - Please Specify:</font> <input type="text" size="24" name="Other_Country" value="<?=$_REQUEST['Other_Country']?>"><br> <font face="Tahoma" size="2" color="#000080">Other Country - Province/State: </font> <input type="text" size="24" name="Province" value="<?=$_REQUEST['Province']?>"></td></tr></table><pre><font face="Tahoma" color="#000080"> *Email Address: </font><input type="text" size="50" name="Email_Address" value="<?=$_REQUEST['Email_Address']?>"></pre><div align="center">    <center> <pre><center><input type="submit" name="Submit" value="Submit Information"></center></pre></center></div></form><p>  </td></tr>   </table><p<p align="left"><font face="Georgia" style="font-size: 11.5pt"><i>Breaking into Print</i> is recommended for college credits by the Connecticut Board for State Academic Awards and approved by the Connecticut Commissioner of Higher Education.</font></p><?php include("footer.htm")?> </body>