<![CDATA[
<body bgcolor="#FFFFFF" text="#000000" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0">
<table width="700" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="10"> </td>
<td valign="top">
<div align="center"><img src="novasonic.gif" width="550" height="138" alt="Novasonic"></div>
</td>
<td width="10"> </td>
</tr>
<tr>
<td width="10"> </td>
<td>
<div align="center"><font size="7"color="#FF0000">This site uses Frames
and Layers<br>
which requires a compatable<br>
browser to view them.</font></div>
</td>
<td width="10"> </td>
</tr>
<tr>
<td width="10"> </td>
<td>
<div align="center"><font size="6"color="#0000FF">Alternativley you can
request a brochure to be<br>
delivered to your door.</font><font size="3"><br>
<br>
<font color="#FF0000">#</font> = REQUIRES DETAILS</font></div>
</td>
<td width="10"> </td>
</tr>
<tr>
<td width="10"> </td>
<td valign="top">
<div align="center">
<form method="post" action="/cgi-bin/mailform.pl">
<input type=hidden name="recipient" value="brochures@novasonic-therapy.co.uk">
<input type=hidden name="redirect" value="http://www.novasonic-therapy.co.uk/thankyou.htm">
<input type=hidden name="subject" value="Novasonic Brochure Request (NO FRAMES)">
<input type=hidden name="required" value="FirstName,Surname,Address1,Town/City,FindUs">
<input type=hidden name="env_report" value="REMOTE_HOST,REMOTE_ADDR,REMOTE_USER,HTTP_USER_AGENT">
<input type=hidden name="print_blank_fields" value="1">
<input type="hidden" name="realname" value="Novasonic">
Title:
<select name="Title" size="1">
<option>Select</option>
<option value="Mr">Mr</option>
<option value="Mrs">Mrs</option>
<option value="Miss">Miss</option>
<option value="Ms">Ms</option>
<option value="Dr">Dr</option>
<option value="Prof">Prof</option>
<option value="Other">Other</option>
</select>
<font color="#FF0000">#</font> First Name:
<input type="text" name="FirstName" size="15">
<font color="#FF0000">#</font> Surname:
<input type="text" name="Surname" size="20">
<br>
<br>
<font color="#FF0000">#</font> Address Line 1:
<input type="text" name="Address1" size="50">
<br>
Address Line 2:
<input type="text" name="Address2" size="50">
<br>
Address Line 3:
<input type="text" name="Address3" size="50">
<br>
<br>
<font color="#FF0000">#</font> Town/City:
<input type="text" name="Town/City" size="20">
<font color="#FF0000">#</font> County/Region:
<input type="text" name="Countty/Region" size="20">
<br>
<font color="#FF0000">#</font> PostCode:
<input type="text" name="PostCode" size="15">
Country:
<input type="text" name="Country" size="20">
<br>
<br>
Email:
<input type="text" name="Email" size="25">
Tel:
<input type="text" name="Telephone" size="25">
<br>
<br>
<i><b><font size="4">Please check the products you would like to receive
information about:<br>
Novasonic Therapy
<input type="checkbox" name="Novasonic Therapy" value="Brochure Please">
Pedilux Footcare
<input type="checkbox" name="Pedilux Footcare" value="Brochure Please">
</font></b></i><br>
<br>
<font color="#FF0000">#</font> How did you find this web site?:
<select name="FindUs" size="1">
<option>Select One</option>
<option value="Internet Search">Internet Search</option>
<option value="Recommendation">Recommendation</option>
<option value="News Paper Advert">News Paper Advert</option>
</select>
<br>
<font color="#FF0000">#</font> If "News Paper Advert" Please enter the
code on bottom right of your coupon:
<input type="text" name="MediaCode" size="10">
<br>
<br>
Check that all your details are present and correct<br>
Then press "Submit". <font color="#FF0000">Once ONLY.</font><br>
<br>
<p></p>
<center>
<font size="3">
<input type="submit" value="Submit" name="Submit">
<input type="Reset" value="Reset" name="Reset">
<br>
<br>
<font color="#FF0000"><u>We Promise never to telephone or knock on
your door on a sales call.</u></font></font>
</center>
</form>
</div>
</td>
<td width="10"> </td>
</tr>
</table>
</body>
]]>