<html><head><title>For More Information</title><SCRIPT LANGUAGE="JavaScript"> function checkType() { if (document.form1.rush.checked) { document.form1.action = "http://www.navioo.com"; } }</SCRIPT></head> <body><h1>Order Form</h1><hr><form name="form1" action="http://www.navioo.com"method="POST" onSubmit="checkType()"><p>Please provide the following contact information:</p><blockquote><pre> <em>First name </em> <input type=text size=25 maxlength=256 name="Contact_FirstName"> <em>Last name </em> <input type=text size=25 maxlength=256 name="Contact_LastName"> <em>Title </em> <input type=text size=35 maxlength=256 name="Contact_Title"> <em>Organization </em> <input type=text size=35 maxlength=256 name="Contact_Organization"> <em>Work Phone </em> <input type=text size=25 maxlength=25 name="Contact_WorkPhone"> <em>FAX </em> <input type=text size=25 maxlength=25 name="Contact_FAX"> <em>E-mail </em> <input type=text size=25 maxlength=256 name="Contact_Email"> <em>URL </em><input type=text size=25 maxlength=25 name="Contact_URL"></pre></blockquote><p>Please provide the following ordering information:</p><blockquote><pre> <strong>QTY DESCRIPTION</strong> <input type=text size=6 maxlength=6 name="Ordering_OrderQty0"> <input type=text size=45 maxlength=256 name="Ordering_OrderDesc0"> <input type=text size=6 maxlength=6 name="Ordering_OrderQty1"> <input type=text size=45 maxlength=256 name="Ordering_OrderDesc1"> <input type=text size=6 maxlength=6 name="Ordering_OrderQty2"> <input type=text size=45 maxlength=256 name="Ordering_OrderDesc2"> <input type=text size=6 maxlength=6 name="Ordering_OrderQty3"> <input type=text size=45 maxlength=256 name="Ordering_OrderDesc3"> <input type=text size=6 maxlength=6 name="Ordering_OrderQty4"> <input type=text size=45 maxlength=256 name="Ordering_OrderDesc4"> <strong>BILLING</strong> <em>Purchase order # </em> <input type=text size=25 maxlength=256 name="Ordering_PONumber"> <em>Account name </em> <input type=text size=25 maxlength=256 name="Ordering_POAccount"> <strong>SHIPPING</strong> <em> Street address </em> <input type=text size=35 maxlength=256 name="Ordering_StreetAddress"> <em> Address (cont.) </em> <input type=text size=35 maxlength=256 name="Ordering_Address2"> <em>City </em> <input type=text size=35 maxlength=256 name="Ordering_City"> <em> State/Province </em> <input type=text size=35 maxlength=256 name="Ordering_State"> <em> Zip/Postal code </em> <input type=text size=12 maxlength=12 name="Ordering_ZipCode"> <em> Country </em> <input type=text size=25 maxlength=256 name="Ordering_Country"></pre><pre> <input type=checkbox name="rush" value="ON">Rush Order!</pre></blockquote><p> <input type=submit value="Submit Form"> <input type=reset value="Reset Form"> </p></form></body></html>
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