<p class="fontlook2">

<p class="fontlook"><FORM METHOD="post" ACTION="pag.pl">

<TABLE cellpadding=0 border=0>

<TR>
<TD class="fontlookc" align=center colspan=2><B>Your Information</B>
</TR>

<TR>
<TD class="fontlookc" align="right">Title: </TD>
<TD class="fontlookc" align=left>
<SELECT name="title">
<option>--</option>
<option>Mr.</option>
<option>Mrs.</option>
<option>Ms.</option>
<option>Dr.</option>
<option>Other</option>
</SELECT>
</TD>
</TR>

<TR>
<TD class="fontlookc" align=right> First Name: </TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>

<TR>
<TD class="fontlookc" align=right> Last Name: </TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>

<TR>
<TD class="fontlookc" align=right> Email: </TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>

<TR>
<TD class="fontlookc" align=right> Phone: </TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>

<TR>
<TD class="fontlookc" align=center colspan=2><B>Giving Information</B>
</TR>


<TR>
<TD class="fontlookc" align=right valign=top>Relationship to School<BR>
(check all that apply) </TD>

<TD class="fontlookc" align=left valign=top>
	<TABLE cellpadding=0 cellspacing=0 width=100%>
		<TR>
		 <TD class="fontlookc"><input type="checkbox" name="relationship" value="CurrParent">Current Parent</TD>
		 <TD class="fontlookc"><input type="checkbox" name="relationship" value="Alumnus">Alumnus</TD>
		</TR>
		 <TD class="fontlookc"><input type="checkbox" name="relationship" value="AlumParent">Parent of Alum</TD>
		 <TD class="fontlookc"><input type="checkbox" name="relationship" value="GrandParent">Grandparent</TD>
		</TR>
		<TR>
		 <TD class="fontlookc"><input type="checkbox" name="relationship" value="Friend">Friend</TD>
		 <TD class="fontlookc"><input type="checkbox" name="relationship" value="FacStaff">Faculty / Staff</TD>
		</TR>
		<TR>
		 <TD class="fontlookc" colspan=2><input type="checkbox" name="relationship" value="Other">Other: <input type="text" name="other" size=30></TD>
		</TR>
	</TABLE>
</TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Name of Donor(s)</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Matching Donor (if any)</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=center colspan=2><B>Address</B>
</TR>


<TR>
<TD class="fontlookc" align=right>Address</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Address 2</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>City</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Zip Code</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>State</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Country</TD>
<TD class="fontlookc" align=left><SELECT name="country">
<option value=""></option> 
<option value="Afghanistan">Afghanistan</option> 
<option value="Åland Islands">Åland Islands</option> 
<option value="Albania">Albania</option> 
<option value="Algeria">Algeria</option> 
<option value="American Samoa">American Samoa</option> 
<option value="Andorra">Andorra</option> 
<option value="Angola">Angola</option> 
<option value="Anguilla">Anguilla</option> 
<option value="Antarctica">Antarctica</option> 
<option value="Antigua and Barbuda">Antigua and Barbuda</option> 
<option value="Argentina">Argentina</option> 
<option value="Armenia">Armenia</option> 
<option value="Aruba">Aruba</option> 
<option value="Australia">Australia</option> 
<option value="Austria">Austria</option> 
<option value="Azerbaijan">Azerbaijan</option> 
<option value="Bahamas">Bahamas</option> 
<option value="Bahrain">Bahrain</option> 
<option value="Bangladesh">Bangladesh</option> 
<option value="Barbados">Barbados</option> 
<option value="Belarus">Belarus</option> 
<option value="Belgium">Belgium</option> 
<option value="Belize">Belize</option> 
<option value="Benin">Benin</option> 
<option value="Bermuda">Bermuda</option> 
<option value="Bhutan">Bhutan</option> 
<option value="Bolivia">Bolivia</option> 
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> 
<option value="Botswana">Botswana</option> 
<option value="Bouvet Island">Bouvet Island</option> 
<option value="Brazil">Brazil</option> 
<option value="British Indian Ocean territory">British Indian Ocean territory</option> 
<option value="Brunei Darussalam">Brunei Darussalam</option> 
<option value="Bulgaria">Bulgaria</option> 
<option value="Burkina Faso">Burkina Faso</option> 
<option value="Burundi">Burundi</option> 
<option value="Cambodia">Cambodia</option> 
<option value="Cameroon">Cameroon</option> 
<option value="Canada">Canada</option> 
<option value="Cape Verde">Cape Verde</option> 
<option value="Cayman Islands">Cayman Islands</option> 
<option value="Central African Republic">Central African Republic</option> 
<option value="Chad">Chad</option> 
<option value="Chile">Chile</option> 
<option value="China">China</option> 
<option value="Christmas Island">Christmas Island</option> 
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option> 
<option value="Colombia">Colombia</option> 
<option value="Comoros">Comoros</option> 
<option value="Congo">Congo</option> 
<option value="Congo, Democratic Republic">Congo, Democratic Republic</option> 
<option value="Cook Islands">Cook Islands</option> 
<option value="Costa Rica">Costa Rica</option> 
<option value="Côte d'Ivoire (Ivory Coast)">Côte d'Ivoire (Ivory Coast)</option> 
<option value="Croatia (Hrvatska)">Croatia (Hrvatska)</option> 
<option value="Cuba">Cuba</option> 
<option value="Cyprus">Cyprus</option> 
<option value="Czech Republic">Czech Republic</option> 
<option value="Denmark">Denmark</option> 
<option value="Djibouti">Djibouti</option> 
<option value="Dominica">Dominica</option> 
<option value="Dominican Republic">Dominican Republic</option> 
<option value="East Timor">East Timor</option> 
<option value="Ecuador">Ecuador</option> 
<option value="Egypt">Egypt</option> 
<option value="El Salvador">El Salvador</option> 
<option value="Equatorial Guinea">Equatorial Guinea</option> 
<option value="Eritrea">Eritrea</option> 
<option value="Estonia">Estonia</option> 
<option value="Ethiopia">Ethiopia</option> 
<option value="Falkland Islands">Falkland Islands</option> 
<option value="Faroe Islands">Faroe Islands</option> 
<option value="Fiji">Fiji</option> 
<option value="Finland">Finland</option> 
<option value="France">France</option> 
<option value="French Guiana">French Guiana</option> 
<option value="French Polynesia">French Polynesia</option> 
<option value="French Southern Territories">French Southern Territories</option> 
<option value="Gabon">Gabon</option> 
<option value="Gambia">Gambia</option> 
<option value="Georgia">Georgia</option> 
<option value="Germany">Germany</option> 
<option value="Ghana">Ghana</option> 
<option value="Gibraltar">Gibraltar</option> 
<option value="Greece">Greece</option> 
<option value="Greenland">Greenland</option> 
<option value="Grenada">Grenada</option> 
<option value="Guadeloupe">Guadeloupe</option> 
<option value="Guam">Guam</option> 
<option value="Guatemala">Guatemala</option> 
<option value="Guinea">Guinea</option> 
<option value="Guinea-Bissau">Guinea-Bissau</option> 
<option value="Guyana">Guyana</option> 
<option value="Haiti">Haiti</option> 
<option value="Heard and McDonald Islands">Heard and McDonald Islands</option> 
<option value="Honduras">Honduras</option> 
<option value="Hong Kong">Hong Kong</option> 
<option value="Hungary">Hungary</option> 
<option value="Iceland">Iceland</option> 
<option value="India">India</option> 
<option value="Indonesia">Indonesia</option> 
<option value="Iran">Iran</option> 
<option value="Iraq">Iraq</option> 
<option value="Ireland">Ireland</option> 
<option value="Israel">Israel</option> 
<option value="Italy">Italy</option> 
<option value="Jamaica">Jamaica</option> 
<option value="Japan">Japan</option> 
<option value="Jordan">Jordan</option> 
<option value="Kazakhstan">Kazakhstan</option> 
<option value="Kenya">Kenya</option> 
<option value="Kiribati">Kiribati</option> 
<option value="Korea (north)">Korea (north)</option> 
<option value="Korea (south)">Korea (south)</option> 
<option value="Kuwait">Kuwait</option> 
<option value="Kyrgyzstan">Kyrgyzstan</option> 
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option> 
<option value="Latvia">Latvia</option> 
<option value="Lebanon">Lebanon</option> 
<option value="Lesotho">Lesotho</option> 
<option value="Liberia">Liberia</option> 
<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option> 
<option value="Liechtenstein">Liechtenstein</option> 
<option value="Lithuania">Lithuania</option> 
<option value="Luxembourg">Luxembourg</option> 
<option value="Macao">Macao</option> 
<option value="Macedonia">Macedonia</option> 
<option value="Madagascar">Madagascar</option> 
<option value="Malawi">Malawi</option> 
<option value="Malaysia">Malaysia</option> 
<option value="Maldives">Maldives</option> 
<option value="Mali">Mali</option> 
<option value="Malta">Malta</option> 
<option value="Marshall Islands">Marshall Islands</option> 
<option value="Martinique">Martinique</option> 
<option value="Mauritania">Mauritania</option> 
<option value="Mauritius">Mauritius</option> 
<option value="Mayotte">Mayotte</option> 
<option value="Mexico">Mexico</option> 
<option value="Micronesia">Micronesia</option> 
<option value="Moldova">Moldova</option> 
<option value="Monaco">Monaco</option> 
<option value="Mongolia">Mongolia</option> 
<option value="Montserrat">Montserrat</option> 
<option value="Morocco">Morocco</option> 
<option value="Mozambique">Mozambique</option> 
<option value="Myanmar">Myanmar</option> 
<option value="Namibia">Namibia</option> 
<option value="Nauru">Nauru</option> 
<option value="Nepal">Nepal</option> 
<option value="Netherlands">Netherlands</option> 
<option value="Netherlands Antilles">Netherlands Antilles</option> 
<option value="New Caledonia">New Caledonia</option> 
<option value="New Zealand">New Zealand</option> 
<option value="Nicaragua">Nicaragua</option> 
<option value="Niger">Niger</option> 
<option value="Nigeria">Nigeria</option> 
<option value="Niue">Niue</option> 
<option value="Norfolk Island">Norfolk Island</option> 
<option value="Northern Mariana Islands">Northern Mariana Islands</option> 
<option value="Norway">Norway</option> 
<option value="Oman">Oman</option> 
<option value="Pakistan">Pakistan</option> 
<option value="Palau">Palau</option> 
<option value="Palestinian Territories">Palestinian Territories</option> 
<option value="Panama">Panama</option> 
<option value="Papua New Guinea">Papua New Guinea</option> 
<option value="Paraguay">Paraguay</option> 
<option value="Peru">Peru</option> 
<option value="Philippines">Philippines</option> 
<option value="Pitcairn">Pitcairn</option> 
<option value="Poland">Poland</option> 
<option value="Portugal">Portugal</option> 
<option value="Puerto Rico">Puerto Rico</option> 
<option value="Qatar">Qatar</option> 
<option value="Réunion">Réunion</option> 
<option value="Romania">Romania</option> 
<option value="Russian Federation">Russian Federation</option> 
<option value="Rwanda">Rwanda</option> 
<option value="Saint Helena">Saint Helena</option> 
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> 
<option value="Saint Lucia">Saint Lucia</option> 
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option> 
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> 
<option value="Samoa">Samoa</option> 
<option value="San Marino">San Marino</option> 
<option value="Sao Tome and Principe">Sao Tome and Principe</option> 
<option value="Saudi Arabia">Saudi Arabia</option> 
<option value="Senegal">Senegal</option> 
<option value="Serbia and Montenegro">Serbia and Montenegro</option> 
<option value="Seychelles">Seychelles</option> 
<option value="Sierra Leone">Sierra Leone</option> 
<option value="Singapore">Singapore</option> 
<option value="Slovakia">Slovakia</option> 
<option value="Slovenia">Slovenia</option> 
<option value="Solomon Islands">Solomon Islands</option> 
<option value="Somalia">Somalia</option> 
<option value="South Africa">South Africa</option> 
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option> 
<option value="Spain">Spain</option> 
<option value="Sri Lanka">Sri Lanka</option> 
<option value="Sudan">Sudan</option> 
<option value="Suriname">Suriname</option> 
<option value="Svalbard and Jan Mayen Islands">Svalbard and Jan Mayen Islands</option> 
<option value="Swaziland">Swaziland</option> 
<option value="Sweden">Sweden</option> 
<option value="Switzerland">Switzerland</option> 
<option value="Syria">Syria</option> 
<option value="Taiwan">Taiwan</option> 
<option value="Tajikistan">Tajikistan</option> 
<option value="Tanzania">Tanzania</option> 
<option value="Thailand">Thailand</option> 
<option value="Togo">Togo</option> 
<option value="Tokelau">Tokelau</option> 
<option value="Tonga">Tonga</option> 
<option value="Trinidad and Tobago">Trinidad and Tobago</option> 
<option value="Tunisia">Tunisia</option> 
<option value="Turkey">Turkey</option> 
<option value="Turkmenistan">Turkmenistan</option> 
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option> 
<option value="Tuvalu">Tuvalu</option> 
<option value="Uganda">Uganda</option> 
<option value="Ukraine">Ukraine</option> 
<option value="United Arab Emirates">United Arab Emirates</option> 
<option value="United Kingdom">United Kingdom</option> 
<option value="USA">United States of America</option> 
<option value="Uruguay">Uruguay</option> 
<option value="Uzbekistan">Uzbekistan</option> 
<option value="Vanuatu">Vanuatu</option> 
<option value="Vatican City">Vatican City</option> 
<option value="Venezuela">Venezuela</option> 
<option value="Vietnam">Vietnam</option> 
<option value="Virgin Islands (British)">Virgin Islands (British)</option> 
<option value="Virgin Islands (US)">Virgin Islands (US)</option> 
<option value="Wallis and Futuna Islands">Wallis and Futuna Islands</option> 
<option value="Western Sahara">Western Sahara</option> 
<option value="Yemen">Yemen</option> 
<option value="Zaire">Zaire</option> 
<option value="Zambia">Zambia</option> 
<option value="Zimbabwe">Zimbabwe</option> 
</select> 
</TD>
</TR>


<!--TR>
<TD class="fontlookc" align=center colspan=2><B>Tribute Gifts</B>
</TR>


<TR>
<TD class="fontlookc" align=right>Tribute Type</TD>
<TD class="fontlookc" align=left><select id="tribute" name="tribute"> 
						<option value="" selected="selected">----</option> 
						<option value="honor">This gift is in honor of...</option> 
						<option value="memory">This gift is in memory of...</option> 
					</select> </TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Name</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>

 
<TR>
<TD class="fontlookc" align=center colspan=2><input type="checkbox" name="tributeNotifyAcknowledgement" value="yes">Please send an acknowledgement of this tribute...</TD>
</TR>

<TR>
<TD class="fontlookc" align=right>Name</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Address</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Address 2</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>City</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Zip Code</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>State</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Country</TD>
<TD class="fontlookc" align=left><SELECT name="tributeCountry">
<option value=""></option> 
<option value="Afghanistan">Afghanistan</option> 
<option value="Åland Islands">Åland Islands</option> 
<option value="Albania">Albania</option> 
<option value="Algeria">Algeria</option> 
<option value="American Samoa">American Samoa</option> 
<option value="Andorra">Andorra</option> 
<option value="Angola">Angola</option> 
<option value="Anguilla">Anguilla</option> 
<option value="Antarctica">Antarctica</option> 
<option value="Antigua and Barbuda">Antigua and Barbuda</option> 
<option value="Argentina">Argentina</option> 
<option value="Armenia">Armenia</option> 
<option value="Aruba">Aruba</option> 
<option value="Australia">Australia</option> 
<option value="Austria">Austria</option> 
<option value="Azerbaijan">Azerbaijan</option> 
<option value="Bahamas">Bahamas</option> 
<option value="Bahrain">Bahrain</option> 
<option value="Bangladesh">Bangladesh</option> 
<option value="Barbados">Barbados</option> 
<option value="Belarus">Belarus</option> 
<option value="Belgium">Belgium</option> 
<option value="Belize">Belize</option> 
<option value="Benin">Benin</option> 
<option value="Bermuda">Bermuda</option> 
<option value="Bhutan">Bhutan</option> 
<option value="Bolivia">Bolivia</option> 
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> 
<option value="Botswana">Botswana</option> 
<option value="Bouvet Island">Bouvet Island</option> 
<option value="Brazil">Brazil</option> 
<option value="British Indian Ocean territory">British Indian Ocean territory</option> 
<option value="Brunei Darussalam">Brunei Darussalam</option> 
<option value="Bulgaria">Bulgaria</option> 
<option value="Burkina Faso">Burkina Faso</option> 
<option value="Burundi">Burundi</option> 
<option value="Cambodia">Cambodia</option> 
<option value="Cameroon">Cameroon</option> 
<option value="Canada">Canada</option> 
<option value="Cape Verde">Cape Verde</option> 
<option value="Cayman Islands">Cayman Islands</option> 
<option value="Central African Republic">Central African Republic</option> 
<option value="Chad">Chad</option> 
<option value="Chile">Chile</option> 
<option value="China">China</option> 
<option value="Christmas Island">Christmas Island</option> 
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option> 
<option value="Colombia">Colombia</option> 
<option value="Comoros">Comoros</option> 
<option value="Congo">Congo</option> 
<option value="Congo, Democratic Republic">Congo, Democratic Republic</option> 
<option value="Cook Islands">Cook Islands</option> 
<option value="Costa Rica">Costa Rica</option> 
<option value="Côte d'Ivoire (Ivory Coast)">Côte d'Ivoire (Ivory Coast)</option> 
<option value="Croatia (Hrvatska)">Croatia (Hrvatska)</option> 
<option value="Cuba">Cuba</option> 
<option value="Cyprus">Cyprus</option> 
<option value="Czech Republic">Czech Republic</option> 
<option value="Denmark">Denmark</option> 
<option value="Djibouti">Djibouti</option> 
<option value="Dominica">Dominica</option> 
<option value="Dominican Republic">Dominican Republic</option> 
<option value="East Timor">East Timor</option> 
<option value="Ecuador">Ecuador</option> 
<option value="Egypt">Egypt</option> 
<option value="El Salvador">El Salvador</option> 
<option value="Equatorial Guinea">Equatorial Guinea</option> 
<option value="Eritrea">Eritrea</option> 
<option value="Estonia">Estonia</option> 
<option value="Ethiopia">Ethiopia</option> 
<option value="Falkland Islands">Falkland Islands</option> 
<option value="Faroe Islands">Faroe Islands</option> 
<option value="Fiji">Fiji</option> 
<option value="Finland">Finland</option> 
<option value="France">France</option> 
<option value="French Guiana">French Guiana</option> 
<option value="French Polynesia">French Polynesia</option> 
<option value="French Southern Territories">French Southern Territories</option> 
<option value="Gabon">Gabon</option> 
<option value="Gambia">Gambia</option> 
<option value="Georgia">Georgia</option> 
<option value="Germany">Germany</option> 
<option value="Ghana">Ghana</option> 
<option value="Gibraltar">Gibraltar</option> 
<option value="Greece">Greece</option> 
<option value="Greenland">Greenland</option> 
<option value="Grenada">Grenada</option> 
<option value="Guadeloupe">Guadeloupe</option> 
<option value="Guam">Guam</option> 
<option value="Guatemala">Guatemala</option> 
<option value="Guinea">Guinea</option> 
<option value="Guinea-Bissau">Guinea-Bissau</option> 
<option value="Guyana">Guyana</option> 
<option value="Haiti">Haiti</option> 
<option value="Heard and McDonald Islands">Heard and McDonald Islands</option> 
<option value="Honduras">Honduras</option> 
<option value="Hong Kong">Hong Kong</option> 
<option value="Hungary">Hungary</option> 
<option value="Iceland">Iceland</option> 
<option value="India">India</option> 
<option value="Indonesia">Indonesia</option> 
<option value="Iran">Iran</option> 
<option value="Iraq">Iraq</option> 
<option value="Ireland">Ireland</option> 
<option value="Israel">Israel</option> 
<option value="Italy">Italy</option> 
<option value="Jamaica">Jamaica</option> 
<option value="Japan">Japan</option> 
<option value="Jordan">Jordan</option> 
<option value="Kazakhstan">Kazakhstan</option> 
<option value="Kenya">Kenya</option> 
<option value="Kiribati">Kiribati</option> 
<option value="Korea (north)">Korea (north)</option> 
<option value="Korea (south)">Korea (south)</option> 
<option value="Kuwait">Kuwait</option> 
<option value="Kyrgyzstan">Kyrgyzstan</option> 
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option> 
<option value="Latvia">Latvia</option> 
<option value="Lebanon">Lebanon</option> 
<option value="Lesotho">Lesotho</option> 
<option value="Liberia">Liberia</option> 
<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option> 
<option value="Liechtenstein">Liechtenstein</option> 
<option value="Lithuania">Lithuania</option> 
<option value="Luxembourg">Luxembourg</option> 
<option value="Macao">Macao</option> 
<option value="Macedonia">Macedonia</option> 
<option value="Madagascar">Madagascar</option> 
<option value="Malawi">Malawi</option> 
<option value="Malaysia">Malaysia</option> 
<option value="Maldives">Maldives</option> 
<option value="Mali">Mali</option> 
<option value="Malta">Malta</option> 
<option value="Marshall Islands">Marshall Islands</option> 
<option value="Martinique">Martinique</option> 
<option value="Mauritania">Mauritania</option> 
<option value="Mauritius">Mauritius</option> 
<option value="Mayotte">Mayotte</option> 
<option value="Mexico">Mexico</option> 
<option value="Micronesia">Micronesia</option> 
<option value="Moldova">Moldova</option> 
<option value="Monaco">Monaco</option> 
<option value="Mongolia">Mongolia</option> 
<option value="Montserrat">Montserrat</option> 
<option value="Morocco">Morocco</option> 
<option value="Mozambique">Mozambique</option> 
<option value="Myanmar">Myanmar</option> 
<option value="Namibia">Namibia</option> 
<option value="Nauru">Nauru</option> 
<option value="Nepal">Nepal</option> 
<option value="Netherlands">Netherlands</option> 
<option value="Netherlands Antilles">Netherlands Antilles</option> 
<option value="New Caledonia">New Caledonia</option> 
<option value="New Zealand">New Zealand</option> 
<option value="Nicaragua">Nicaragua</option> 
<option value="Niger">Niger</option> 
<option value="Nigeria">Nigeria</option> 
<option value="Niue">Niue</option> 
<option value="Norfolk Island">Norfolk Island</option> 
<option value="Northern Mariana Islands">Northern Mariana Islands</option> 
<option value="Norway">Norway</option> 
<option value="Oman">Oman</option> 
<option value="Pakistan">Pakistan</option> 
<option value="Palau">Palau</option> 
<option value="Palestinian Territories">Palestinian Territories</option> 
<option value="Panama">Panama</option> 
<option value="Papua New Guinea">Papua New Guinea</option> 
<option value="Paraguay">Paraguay</option> 
<option value="Peru">Peru</option> 
<option value="Philippines">Philippines</option> 
<option value="Pitcairn">Pitcairn</option> 
<option value="Poland">Poland</option> 
<option value="Portugal">Portugal</option> 
<option value="Puerto Rico">Puerto Rico</option> 
<option value="Qatar">Qatar</option> 
<option value="Réunion">Réunion</option> 
<option value="Romania">Romania</option> 
<option value="Russian Federation">Russian Federation</option> 
<option value="Rwanda">Rwanda</option> 
<option value="Saint Helena">Saint Helena</option> 
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> 
<option value="Saint Lucia">Saint Lucia</option> 
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option> 
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> 
<option value="Samoa">Samoa</option> 
<option value="San Marino">San Marino</option> 
<option value="Sao Tome and Principe">Sao Tome and Principe</option> 
<option value="Saudi Arabia">Saudi Arabia</option> 
<option value="Senegal">Senegal</option> 
<option value="Serbia and Montenegro">Serbia and Montenegro</option> 
<option value="Seychelles">Seychelles</option> 
<option value="Sierra Leone">Sierra Leone</option> 
<option value="Singapore">Singapore</option> 
<option value="Slovakia">Slovakia</option> 
<option value="Slovenia">Slovenia</option> 
<option value="Solomon Islands">Solomon Islands</option> 
<option value="Somalia">Somalia</option> 
<option value="South Africa">South Africa</option> 
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option> 
<option value="Spain">Spain</option> 
<option value="Sri Lanka">Sri Lanka</option> 
<option value="Sudan">Sudan</option> 
<option value="Suriname">Suriname</option> 
<option value="Svalbard and Jan Mayen Islands">Svalbard and Jan Mayen Islands</option> 
<option value="Swaziland">Swaziland</option> 
<option value="Sweden">Sweden</option> 
<option value="Switzerland">Switzerland</option> 
<option value="Syria">Syria</option> 
<option value="Taiwan">Taiwan</option> 
<option value="Tajikistan">Tajikistan</option> 
<option value="Tanzania">Tanzania</option> 
<option value="Thailand">Thailand</option> 
<option value="Togo">Togo</option> 
<option value="Tokelau">Tokelau</option> 
<option value="Tonga">Tonga</option> 
<option value="Trinidad and Tobago">Trinidad and Tobago</option> 
<option value="Tunisia">Tunisia</option> 
<option value="Turkey">Turkey</option> 
<option value="Turkmenistan">Turkmenistan</option> 
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option> 
<option value="Tuvalu">Tuvalu</option> 
<option value="Uganda">Uganda</option> 
<option value="Ukraine">Ukraine</option> 
<option value="United Arab Emirates">United Arab Emirates</option> 
<option value="United Kingdom">United Kingdom</option> 
<option value="USA">United States of America</option> 
<option value="Uruguay">Uruguay</option> 
<option value="Uzbekistan">Uzbekistan</option> 
<option value="Vanuatu">Vanuatu</option> 
<option value="Vatican City">Vatican City</option> 
<option value="Venezuela">Venezuela</option> 
<option value="Vietnam">Vietnam</option> 
<option value="Virgin Islands (British)">Virgin Islands (British)</option> 
<option value="Virgin Islands (US)">Virgin Islands (US)</option> 
<option value="Wallis and Futuna Islands">Wallis and Futuna Islands</option> 
<option value="Western Sahara">Western Sahara</option> 
<option value="Yemen">Yemen</option> 
<option value="Zaire">Zaire</option> 
<option value="Zambia">Zambia</option> 
<option value="Zimbabwe">Zimbabwe</option> 
</select> </TD>
</TR-->


<TR>
<TD class="fontlookc" align=center colspan=2><B>Payment Information</B>
</TR>


<TR>
<TD class="fontlookc" align=right>Amount (in $)</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Name on Card</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Card Type</TD>
<TD class="fontlookc" align=left><select id="cctype" name="cctype"> 
					<option value="" selected="selected">----</option> 
					<option value="1">MasterCard</option> 
					<option value="2">Visa</option> 
					<option value="3">American Express</option> 
					<option value="4">Discover</option> 
				</select> </TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Number</TD>
<TD class="fontlookc" align=left><input type="name" size=40></TD>
</TR>


<TR>
<TD class="fontlookc" align=right>Expiration</TD>
<TD class="fontlookc" align=left><select name="CCExpireMonth" id="CCExpireMonth"> 
					<option value="">MM</option> 
					<option value="01">1</option> 
					<option value="02">2</option> 
					<option value="03">3</option> 
					<option value="04">4</option> 
					<option value="05">5</option> 
					<option value="06">6</option> 
					<option value="07">7</option> 
					<option value="08">8</option> 
					<option value="09">9</option> 
					<option value="10">10</option> 
					<option value="11">11</option> 
					<option value="12">12</option> 
				</select>  / 
				<select name="CCExpireYear" id="CCExpireYear"> 
					<option value="">YYYY</option> 
					<option value="09">2009</option><option value="10">2010</option><option value="11">2011</option><option value="12">2012</option><option value="13">2013</option><option value="14">2014</option><option value="15">2015</option><option value="16">2016</option><option value="17">2017</option><option value="18">2018</option><option value="19">2019</option> 
				</select> </TD>
</TR>
 

<TR>
<TD class="fontlookc" align=right>Credit Card Security Code</TD>
<TD class="fontlookc" align=left><input type="name" size=5></TD>
</TR>


<TR>
<TD class="fontlookc" align=center colspan=2><B>Comments</B>
</TR>


<TR>
<TD class="fontlookc" align=right>Comments</TD>
<TD class="fontlookc" align=left><textarea name="comments" cols=40 rows=5></textarea></TD>
</TR>

<TR>
<TD></TD>
<TD class="fontlookc" align=left><input type="submit" value="Submit" class="fontlookc"></TD>
</TR>

</TABLE>