<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%>
<%


If (CStr(Request("MM_insert")) <> "") Then


		' send email
		' change to address of your own SMTP server
		strHost = "webmail.webnj.net"

		
		Set Mail = Server.CreateObject("Persits.MailSender")
		' enter valid SMTP host
		Mail.Host = strHost
		Mail.Username = "webinfo@capitolrecoveryservice.com"
		Mail.Password = "webnj"
		Mail.AddAddress "webinfo@capitolrecoveryservice.com"

		Mail.From = Session("webinfo@capitolrecoveryservice.com")
		Mail.FromName = Request("FromName") ' optional
		
		' message subject
		Mail.Subject = "Employment Info sent from www.capitolrecoveryservice.com"
		' message body
		
		Mail.Body = "name              = " + Request("1-Name") + chr(10) + _
					"email             = " + Request("1-E-mail") + chr(10) +  _
					"Address           = " + Request("1-Address") + chr(10) +  _
					"Address2          = " + Request("1-Address2") +  chr(10) +  _
					"city              = " + Request("1-City") + chr(10) +  _
					"state             = " + Request("1-State") + chr(10) +  _
					"zip               = " + Request("1-Zip") + chr(10) +  _
					"phone             = " + Request("1-Phone") +  chr(10) + _
					"dobirth           = " + Request("1-dob") + chr(10) +  _
					"ssn               = " + Request("1-ssn") + chr(10) +  _
					"gender            = " + Request("1-Gender") + chr(10) +  _
					"previous 1        = " + Request("1-Previous 1") +  chr(10) +  _
					"previous 2        = " + Request("1-Previous 2") + chr(10) +  _
					"elementary        = " + Request("2-elementary") + chr(10) +  _
					"2a-years          = " + Request("2a-years") + chr(10) +  _
					"2a-graduate       = " + Request("2a-graduate") +  chr(10) + _
					"2a-degree         = " + Request("2a-degree") + chr(10) +  _
					"middle            = " + Request("2-middle") + chr(10) +  _
					"2b-years          = " + Request("2b-years") + chr(10) +  _
					"2b-graduate       = " + Request("2b-graduate") +  chr(10) + _
					"2b-degree         = " + Request("2b-degree") + chr(10) +  _
					"high              = " + Request("2-high") + chr(10) +  _
					"2c-years          = " + Request("2c-years") + chr(10) +  _
					"2c-graduate       = " + Request("2c-graduate") +  chr(10) + _
					"2c-degree         = " + Request("2c-degree") + chr(10) +  _
					"college           = " + Request("2-college") + chr(10) +  _
					"2d-years          = " + Request("2d-years") + chr(10) +  _
					"2d-graduate       = " + Request("2d-graduate") +  chr(10) + _
					"2d-degree         = " + Request("2d-degree") + chr(10) +  _
					"3-position wanted = " + Request("3-position wanted") + chr(10) +  _
					"3-pay expected    = " + Request("3-pay expected") + chr(10) +  _
					"3-employment type = " + Request("3-employment type") +  chr(10) + _
					"3-special skills  = " + Request("3-special skills") +  chr(10) + _
					"3-equipment       = " + Request("3-equipment") + chr(10) +  _
					"4-military        = " + Request("4-military") + chr(10) +  _
					"4-time in service = " + Request("4-time in service") + chr(10) +  _
					"4-branch          = " + Request("4-branch") +  chr(10) + _
					"4-rank            = " + Request("4-rank") + chr(10) +  _
					"5-convicted       = " + Request("5-convicted") +  chr(10) + _
					"5-charges         = " + Request("5-charges") +  chr(10) + _
					"5-sentence        = " + Request("5-sentence") + chr(10) +  _
					"5-prision term    = " + Request("5-prison term") + chr(10) +  _
					"5-released        = " + Request("5-released") + chr(10) +  _
					"5-us citizen      = " + Request("us citizen?") +  chr(10) + _
					"6-recent employer = " + Request("6-most recent employer") + chr(10) +  _
					"6-supervisor      = " + Request("6-supervisor") + chr(10) +  _
					"6-address         = " + Request("6-address") +  chr(10) + _
					"6-phone           = " + Request("6-phone") + chr(10) +  _
					"6-contact         = " + Request("6-contact") +  chr(10) + _
					"6-reason          = " + Request("6-reason") +  chr(10) + _
					"5-sentence        = " + Request("6-position") + chr(10) +  _
					"6-how long        = " + Request("6-how long") + chr(10) +  _
					"6-pay             = " + Request("6-pay") + chr(10) +  _
					"6-2nd employer    = " + Request("6-2nd recent employer") + chr(10) +  _
					"6a-supervisor     = " + Request("6a-supervisor") + chr(10) +  _
					"6a-address        = " + Request("6a-address") +  chr(10) + _
					"6a-phone          = " + Request("6a-phone") + chr(10) +  _
					"6a-contact        = " + Request("6a-contact") +  chr(10) + _
					"6a-reason         = " + Request("6a-reason") +  chr(10) + _
					"5a-sentence       = " + Request("6a-position") + chr(10) +  _
					"6a-how long       = " + Request("6a-how long") + chr(10) +  _
					"6a-pay            = " + Request("6a-pay") + chr(10) +  _
					"6-3rd employer    = " + Request("6-3rd recent employer") + chr(10) +  _
					"6b-supervisor     = " + Request("6b-supervisor") + chr(10) +  _
					"6b-address        = " + Request("6b-address") +  chr(10) + _
					"6b-phone          = " + Request("6b-phone") + chr(10) +  _
					"6b-contact        = " + Request("6b-contact") +  chr(10) + _
					"6b-reason         = " + Request("6b-reason") +  chr(10) + _
					"5b-sentence       = " + Request("6b-position") + chr(10) +  _
					"6b-how long       = " + Request("6b-how long") + chr(10) +  _
					"6b-pay            = " + Request("6b-pay") + chr(10) +  _
					"7-1st reference   = " + Request("7-1st reference") + chr(10) +  _
					"7a-Address        = " + Request("7a-Address") +  chr(10) +  _
					"7a-city           = " + Request("7a-City") + chr(10) +  _
					"7a-state          = " + Request("7a-State") + chr(10) +  _
					"7a-zip            = " + Request("7a-Zip") + chr(10) +  _
					"7a-phone          = " + Request("7a-Phone") +  chr(10) + _
					"7a-relationship   = " + Request("7a-relationship") + chr(10) +  _
					"7a-contact time   = " + Request("7a-contact time") + chr(10) +  _
					"7-2nd reference   = " + Request("7-2nd reference") + chr(10) +  _
					"7b-Address        = " + Request("7b-Address") +  chr(10) +  _
					"7b-city           = " + Request("7b-City") + chr(10) +  _
					"7b-state          = " + Request("7b-State") + chr(10) +  _
					"7b-zip            = " + Request("7b-Zip") + chr(10) +  _
					"7b-phone          = " + Request("7b-Phone") +  chr(10) + _
					"7b-relationship   = " + Request("7b-relationship") + chr(10) +  _
					"7b-contact time   = " + Request("7b-contact time") + chr(10) +  _
					"7-3rd reference   = " + Request("7-3rd reference") + chr(10) +  _
					"7c-Address        = " + Request("7c-Address") +  chr(10) +  _
					"7c-city           = " + Request("7c-City") + chr(10) +  _
					"7c-state          = " + Request("7c-State") + chr(10) +  _
					"7c-zip            = " + Request("7c-Zip") + chr(10) +  _
					"7c-phone          = " + Request("7c-Phone") +  chr(10) + _
					"7c-relationship   = " + Request("7c-relationship") + chr(10) +  _
					"7c-contact time   = " + Request("7c-contact time") + chr(10) +  _
					"signed            = " + Request("signed") + chr(10) +  _
					"date              = " + Request("date")+ chr(10) 

		strErr = ""
		bSuccess = False
		On Error Resume Next ' catch errors
			Mail.Send	' send message
		If Err <> 0 Then ' error occurred
			strErr = Err.Description
		else
			bSuccess = True
		End If
		Response.Redirect(Request("REDIRECT"))

End If
%>




<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2//EN">
<HTML>
<HEAD>
   <TITLE>Capitol Recovery Service Assignment Form</TITLE>
   <META HTTP-EQUIV="Content-Type" CONTENT="text/html; charset=iso-8859-1">
   <META NAME="Author" CONTENT="John H. Michel">
   <META NAME="GENERATOR" CONTENT="Mozilla/3.01Gold (Win95; I) [Netscape]">
</HEAD>
<BODY TEXT="#004080" BGCOLOR="#FFFFFF" LINK="#0000FF" VLINK="#800080" ALINK="#FF0000" BACKGROUND="bg.jpg">

<UL>
<UL>
<CENTER><P><IMG SRC="header.jpg" HEIGHT=254 WIDTH=350><BR>
<IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550><BR>
<IMG SRC="employ.jpg" HEIGHT=84 WIDTH=397><BR>
<IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550><BR>
<FONT SIZE=+3>Capitol Recovery Service<BR>
</FONT><FONT SIZE=+2>Corporate Headquarters<BR>
</FONT><FONT SIZE=+1>P.O. Box 2206<BR>
Ocean NJ 07712<BR>
Phone: 732.919.7873 | Fax: 732.919.7937<BR>
Toll Free: 800.676.7352</FONT><BR>
		          <form method="post" action="<%=MM_editAction%>" name="form1">
   		<input type="hidden" name="REDIRECT" value="http://www.capitalrecoveryservice.com">
  	   			<input type="hidden" name="MM_insert" value="form1">
<IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Name:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="1-Name"></TD>
</TR>

<TR>
<TD>E-Mail:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="1-E-mail"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="1-Address"></TD>
</TR>

<TR>
<TD>Address:<BR>
(Line 2)</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="1-Address2"></TD>
</TR>

<TR>
<TD>City:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="1-City"></TD>
</TR>

<TR>
<TD>State:</TD>

<TD><INPUT TYPE=text SIZE=2 NAME="1-State"></TD>
</TR>

<TR>
<TD>Zip:</TD>

<TD><INPUT TYPE=text SIZE=5 NAME="1-Zip"></TD>
</TR>

<TR>
<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=12 NAME="1-Phone"></TD>
</TR>

<TR>
<TD>Date of Birth:</TD>

<TD><INPUT TYPE=text SIZE=10 NAME="1-DOB"></TD>
</TR>

<TR>
<TD>Social Security #:</TD>

<TD><INPUT TYPE=text SIZE=15 NAME="1-SSN"></TD>
</TR>

<TR>
<TD>Gender:</TD>

<TD><SELECT NAME="1-Gender"><OPTION>Male <OPTION>Female</SELECT></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR VALIGN=TOP>
<TD>Previous Address 1:</TD>

<TD><TEXTAREA rows=5 cols=20 wrap=physical name="1-Previous 1"></TEXTAREA></TD>
</TR>

<TR VALIGN=TOP>
<TD>Previous Address 2:</TD>

<TD><TEXTAREA rows=5 cols=20 wrap=physical name="1-Previous 2"></TEXTAREA></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD></TD>

<TD>Where Attended</TD>

<TD>Years Attended</TD>

<TD>Did you<BR>
Graduate?</TD>

<TD>Degree(s) Achieved</TD>
</TR>

<TR>
<TD>Elementary School</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2-Elementary"></TD>

<TD><INPUT TYPE=text SIZE=10 NAME="2a-Years"></TD>

<TD><SELECT NAME="2a-Graduate"><OPTION>Yes <OPTION>No</SELECT></TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2a-Degree"></TD>
</TR>

<TR>
<TD>Middle School</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2-Middle"></TD>

<TD><INPUT TYPE=text SIZE=10 NAME="2b-Years"></TD>

<TD><SELECT NAME="2b-Graduate"><OPTION>Yes <OPTION>No</SELECT></TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2b-Degree"></TD>
</TR>

<TR>
<TD>High School</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2-High"></TD>

<TD><INPUT TYPE=text SIZE=10 NAME="2c-Years"></TD>

<TD><SELECT NAME="2c-Graduate"><OPTION>Yes <OPTION>No</SELECT></TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2c-Degree"></TD>
</TR>

<TR>
<TD>College</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2-College"></TD>

<TD><INPUT TYPE=text SIZE=10 NAME="2d-Years"></TD>

<TD><SELECT NAME="2d-Graduate"><OPTION>Yes <OPTION>No</SELECT></TD>

<TD><INPUT TYPE=text SIZE=25 NAME="2d-Degree"></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Position Wanted:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="3-Position Wanted"></TD>
</TR>

<TR>
<TD>Pay Expected:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="3-Pay Expected"></TD>
</TR>

<TR>
<TD>Employment Type:</TD>

<TD><SELECT NAME="3-Employment Type"><OPTION>Full Time<OPTION>Part Time</SELECT></TD>
</TR>

<TR VALIGN=TOP>
<TD>Special Skills:</TD>

<TD><TEXTAREA rows=5 cols=20 wrap=physical name="3-Special Skills"></TEXTAREA></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Please list any equipment you own that may be helpful on the job:</TD>
</TR>

<TR>
<TD><TEXTAREA rows=5 cols=50 wrap=physical name="3-Equipment"></TEXTAREA></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Have you ever served in the Military?</TD>

<TD><SELECT NAME="4-Military"><OPTION>Yes <OPTION>No</SELECT></TD>
</TR>

<TR>
<TD>If so, For how long?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="4-Time in Service"></TD>
</TR>

<TR>
<TD>Which branch did you serve in?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="4-Branch"></TD>
</TR>

<TR>
<TD>What rank did you achieve?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="4-Rank"></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Have you ever been convicted of a crime?</TD>

<TD><SELECT NAME="5-Convicted"><OPTION>Yes<OPTION>No</SELECT></TD>
</TR>

<TR>
<TD>If so, what were you convicted of?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="5-Charges"></TD>
</TR>

<TR>
<TD>What was your sentence?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="5-Sentence"></TD>
</TR>

<TR>
<TD>If imprisoned, for how long?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="5-Prison Term"></TD>
</TR>

<TR>
<TD>When were you released?</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="5-Released"></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Are you currently a U.S. Citizen?</TD>

<TD><SELECT NAME="US Citizen?"><OPTION>Yes<OPTION>No</SELECT></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>Most Recent Employer:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="6-Most Recent Employer"></TD>

<TD>Supervisor:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6-Supervisor"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD ROWSPAN="2"><TEXTAREA rows=3 cols=20 wrap=physical name="6-Address"></TEXTAREA></TD>

<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6-Phone"></TD>
</TR>

<TR>
<TD></TD>

<TD>May we Contact?</TD>

<TD><SELECT NAME="6-Contact"><OPTION>Yes<OPTION>No</SELECT></TD>
</TR>

<TR>
<TD>Reason for Leaving:</TD>

<TD ROWSPAN="3"><TEXTAREA rows=5 cols=20 wrap=physical name="6-Reason"></TEXTAREA></TD>

<TD>Position held:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6-Position"></TD>
</TR>

<TR>
<TD></TD>

<TD>How Long Were you Employed?</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6-How Long"></TD>
</TR>

<TR>
<TD></TD>

<TD>Pay:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6-Pay"></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>2nd Most Recent Employer:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="6-2nd Recent Employer"></TD>

<TD>Supervisor:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6a-Supervisor"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD ROWSPAN="2"><TEXTAREA rows=3 cols=20 wrap=physical name="6a-Address"></TEXTAREA></TD>

<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6a-Phone"></TD>
</TR>

<TR>
<TD></TD>

<TD>May we Contact?</TD>

<TD><SELECT NAME="6a-Contact"><OPTION>Yes<OPTION>No</SELECT></TD>
</TR>

<TR>
<TD>Reason for Leaving:</TD>

<TD ROWSPAN="3"><TEXTAREA rows=5 cols=20 wrap=physical name="6a-Reason"></TEXTAREA></TD>

<TD>Position held:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6a-Position"></TD>
</TR>

<TR>
<TD></TD>

<TD>How Long Were you Employed?</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6a-How Long"></TD>
</TR>

<TR>
<TD></TD>

<TD>Pay:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6a-Pay"></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>3rd Most Recent Employer:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="6-3rd Recent Employer"></TD>

<TD>Supervisor:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6b-Supervisor"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD ROWSPAN="2"><TEXTAREA rows=3 cols=20 wrap=physical name="6b-Address"></TEXTAREA></TD>

<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6b-Phone"></TD>
</TR>

<TR>
<TD></TD>

<TD>May we Contact?</TD>

<TD><SELECT NAME="6b-Contact"><OPTION>Yes<OPTION>No</SELECT></TD>
</TR>

<TR>
<TD>Reason for Leaving:</TD>

<TD ROWSPAN="3"><TEXTAREA rows=5 cols=20 wrap=physical name="6b-Reason"></TEXTAREA></TD>

<TD>Position held:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6b-Position"></TD>
</TR>

<TR>
<TD></TD>

<TD>How Long Were you Employed?</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6b-How Long"></TD>
</TR>

<TR>
<TD></TD>

<TD>Pay:</TD>

<TD><INPUT TYPE=text SIZE=20 NAME="6b-Pay"></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>1st Reference:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7-1st Reference"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7a-Address"></TD>
</TR>

<TR>
<TD>City:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7a-City"></TD>
</TR>

<TR>
<TD>State:</TD>

<TD><INPUT TYPE=text SIZE=2 NAME="7a-State"></TD>
</TR>

<TR>
<TD>Zip:</TD>

<TD><INPUT TYPE=text SIZE=5 NAME="7a-Zip"></TD>
</TR>

<TR>
<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=12 NAME="7a-Phone"></TD>
</TR>

<TR>
<TD>Relationship:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7a-Relationship"></TD>
</TR>

<TR>
<TD>Best Time to Contact:</TD>

<TD><SELECT NAME="7a-Contact Time"><OPTION>Morning<OPTION>Afternoon<OPTION>Night</SELECT></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>2nd Reference:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7-2nd Reference"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7b-Address"></TD>
</TR>

<TR>
<TD>City:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7b-City"></TD>
</TR>

<TR>
<TD>State:</TD>

<TD><INPUT TYPE=text SIZE=2 NAME="7b-State"></TD>
</TR>

<TR>
<TD>Zip:</TD>

<TD><INPUT TYPE=text SIZE=5 NAME="7b-Zip"></TD>
</TR>

<TR>
<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=12 NAME="7b-Phone"></TD>
</TR>

<TR>
<TD>Relationship:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7b-Relationship"></TD>
</TR>

<TR>
<TD>Best Time to Contact:</TD>

<TD><SELECT NAME="7b-Contact Time"><OPTION>Morning<OPTION>Afternoon<OPTION>Night</SELECT></TD>
</TR>
</TABLE></CENTER>

<CENTER><P><IMG SRC="bar.jpg" HEIGHT=17 WIDTH=550></P></CENTER>

<CENTER><TABLE>
<TR>
<TD>3rd Reference:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7-3rd Reference"></TD>
</TR>

<TR>
<TD>Address:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7c-Address"></TD>
</TR>

<TR>
<TD>City:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7c-City"></TD>
</TR>

<TR>
<TD>State:</TD>

<TD><INPUT TYPE=text SIZE=2 NAME="7c-State"></TD>
</TR>

<TR>
<TD>Zip:</TD>

<TD><INPUT TYPE=text SIZE=5 NAME="7c-Zip"></TD>
</TR>

<TR>
<TD>Phone:</TD>

<TD><INPUT TYPE=text SIZE=12 NAME="7c-Phone"></TD>
</TR>

<TR>
<TD>Relationship:</TD>

<TD><INPUT TYPE=text SIZE=25 NAME="7c-Relationship"></TD>
</TR>

<TR>
<TD>Best Time to Contact:</TD>

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