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Subject: [doc-jp 8897] Low Cost Term Life Insurance  OPIQS
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<HTML><FORM action=3D"mailto:lIIIlllIIlllllll@excite.com?subject=3D Insuran=
ce Quote Request" method=3DPOST encType=3Dtext/plain><BODY text=3D#333333 =
vLink=3D#666666 aLink=3D#ff9900 link=3D#333333 bgColor=3D#ffffff><TABLE ce=
llSpacing=3D0 cellPadding=3D0 width=3D600 align=3Dcenter border=3D0><TBODY=
><TR><TD><P style=3D"MARGIN-BOTTOM: -3px"><IMG src=3Dhttp://us.f1.yahoofs.=
com/users/1e1000e9/bc/friends/__hr_head2.jpg?bcQjy88Aw21hXlDN border=3D0><=
/P></TD></TR><TR><TD bgColor=3D#C0C0C0><DIV align=3Dcenter><B><FONT face=3D=
"Verdana, Arial, Helvetica, sans-serif" color=3D#ffffff size=3D2><font fac=
e=3DArial size=3D2>Representing the top 200 Life Insurance Carriers<br> </=
font></FONT></B><FONT face=3D"Verdana, Arial, Helvetica, sans-serif"><B><B=
R><FONT color=3D#4b4b4b size=3D2>Since 1996, term life insurance rates hav=
e been reduced by as much as 70%</FONT><BR><FONT color=3D#ffffff size=3D2>=
40 year old male - $250,000 - 10 year level term</FONT></B></FONT></DIV><D=
IV align=3Dcenter><B><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" =
color=3D#ffffff size=3D2>As low as $11.00 per month!<br></FONT></B></DIV><=
DIV align=3Dcenter>&nbsp;</DIV><DIV align=3Dcenter>&nbsp;</DIV><TABLE cell=
Spacing=3D0 cellPadding=3D1 width=3D500 align=3Dcenter border=3D0><TBODY><=
TR><TD><P style=3D"MARGIN-TOP: -5px; MARGIN-LEFT: 15px; MARGIN-RIGHT: 10px=
"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>At<B> Term=
Quotes Life Insurance Companies of America, </B>we will survey the top lif=
e insurance companies for you and provide you with the best rates availabl=
e.</FONT><P style=3D"MARGIN-LEFT: 15px; MARGIN-RIGHT: 10px"><FONT face=3D"=
Verdana, Arial, Helvetica, sans-serif" size=3D2>The quote is FREE. There i=
s no obligation to buy. Compare the rates and see for yourself. Fill out t=
his quick form below for further information.</FONT></P></TD><TD><IMG src=3D=
http://us.f1.yahoofs.com/users/1e1000e9/bc/friends/happy+family.jpg?bcQjy8=
8AHJwq64ez border=3D0></TD></TR><TR bgcolor=3D#C0C0C0><TD colSpan=3D2><P s=
tyle=3D"MARGIN-BOTTOM: 10px" align=3Dcenter><FONT face=3D"Verdana, Arial, =
Helvetica, sans-serif" size=3D2>&nbsp;Results of computer survey: <font co=
lor=3D#CC3333>01-02-02</font></FONT><FONT face=3D"Arial, Helvetica, sans-s=
erif" color=3D#000000 size=3D2><BR> </FONT><FONT face=3D"Verdana, Arial, H=
elvetica, sans-serif" size=3D2>&nbsp;Sample Annual Premiums</FONT><FONT fa=
ce=3D"Arial, Helvetica, sans-serif" color=3D#000000 size=3D2><BR> </FONT><=
B><font face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#CC3333 siz=
e=3D2>&nbsp;" 10 Year Level Premium Term Rates "</font></B></P><DIV align=3D=
center><CENTER><TABLE cellSpacing=3D1 width=3D400 border=3D0><TBODY><TR bg=
color=3D#000000><TD align=3Dmiddle width=3D100><P style=3D"MARGIN-TOP: 3px=
; MARGIN-BOTTOM: 3px" align=3Dcenter><b><font face=3D"Verdana, Arial, Helv=
etica, sans-serif" color=3D#FFFFFF size=3D2>Age</font></b></P></TD><TD ali=
gn=3Dmiddle width=3D100><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><=
b><font face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#FFFFFF siz=
e=3D2>$250,000</font></b></P></TD><TD align=3Dmiddle width=3D100><P style=3D=
"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><b><font face=3D"Verdana, Arial, Hel=
vetica, sans-serif" color=3D#FFFFFF size=3D2>$500,000</font></b></P></TD><=
TD align=3Dmiddle width=3D100><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: =
3px"><b><font face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#FFFF=
FF size=3D2>$1,000,000</font></b></P></TD></TR><TR><TD align=3Dmiddle widt=
h=3D100 bgColor=3D#3974AE><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"=
 align=3Dcenter><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" color=
=3D#ffffff size=3D2>35</FONT></P></TD><TD align=3Dmiddle width=3D100 bgCol=
or=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D=
"Verdana, Arial, Helvetica, sans-serif" color=3D#FFFFFF size=3D2>$115</fon=
t></P></TD><TD align=3Dmiddle width=3D100 bgColor=3D#6699CC><P style=3D"MA=
RGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica=
, sans-serif" color=3D#ffffff size=3D2>$180</FONT></P></TD><TD align=3Dmid=
dle width=3D100 bgColor=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTT=
OM: 3px"><font face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#FFF=
FFF size=3D2>$300</font></P></TD></TR><TR><TD align=3Dmiddle width=3D100 b=
gColor=3D#3974AE><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px" align=3D=
center><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#fffff=
f size=3D2>45</FONT></P></TD><TD align=3Dmiddle width=3D100 bgColor=3D#669=
9CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D"Verdana=
, Arial, Helvetica, sans-serif" color=3D#FFFFFF size=3D2>$210</font></P></=
TD><TD align=3Dmiddle width=3D100 bgColor=3D#6699CC><P style=3D"MARGIN-TOP=
: 3px; MARGIN-BOTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sans-s=
erif" color=3D#ffffff size=3D2>$370</FONT></P></TD><TD align=3Dmiddle widt=
h=3D100 bgColor=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"=
><font face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#FFFFFF size=
=3D2>$640</font></P></TD></TR><TR><TD align=3Dmiddle width=3D100 bgColor=3D=
#3974AE><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px" align=3Dcenter><F=
ONT face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#ffffff size=3D=
2>55</FONT></P></TD><TD align=3Dmiddle width=3D100 bgColor=3D#6699CC><P st=
yle=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D"Verdana, Arial, =
Helvetica, sans-serif" color=3D#FFFFFF size=3D2>$475</font></P></TD><TD al=
ign=3Dmiddle width=3D100 bgColor=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MA=
RGIN-BOTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" col=
or=3D#ffffff size=3D2>$880</FONT></P></TD><TD align=3Dmiddle width=3D100 b=
gColor=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font fa=
ce=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#FFFFFF size=3D2>$1,6=
90</font></P></TD></TR><TR><TD align=3Dmiddle width=3D100 bgColor=3D#3974A=
E><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px" align=3Dcenter><FONT fa=
ce=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#ffffff size=3D2>65</=
FONT></P></TD><TD align=3Dmiddle width=3D100 bgColor=3D#6699CC><P style=3D=
"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D"Verdana, Arial, Helvet=
ica, sans-serif" color=3D#FFFFFF size=3D2>$1,248</font></P></TD><TD align=3D=
middle width=3D100 bgColor=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-B=
OTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#=
ffffff size=3D2>$2,425</FONT></P></TD><TD align=3Dmiddle width=3D100 bgCol=
or=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D=
"Verdana, Arial, Helvetica, sans-serif" color=3D#FFFFFF size=3D2>$4,700</f=
ont></P></TD></TR><TR><TD align=3Dmiddle width=3D100 bgColor=3D#3974AE><P =
style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px" align=3Dcenter><FONT face=3D=
"Verdana, Arial, Helvetica, sans-serif" color=3D#ffffff size=3D2>70</FONT>=
</P></TD><TD align=3Dmiddle width=3D100 bgColor=3D#6699CC><P style=3D"MARG=
IN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D"Verdana, Arial, Helvetica, =
sans-serif" color=3D#FFFFFF size=3D2>$1,898</font></P></TD><TD align=3Dmid=
dle width=3D100 bgColor=3D#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTT=
OM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" color=3D#fff=
fff size=3D2>$3,725</FONT></P></TD><TD align=3Dmiddle width=3D100 bgColor=3D=
#6699CC><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><font face=3D"Ver=
dana, Arial, Helvetica, sans-serif" color=3D#FFFFFF size=3D2>$7,380</font>=
</P></TD></TR></TBODY></TABLE></CENTER></DIV><P style=3D"MARGIN-TOP: 4px; =
MARGIN-LEFT: 50px; MARGIN-RIGHT: 50px" align=3Dcenter><FONT face=3D"Verdan=
a, Arial, Helvetica, sans-serif" size=3D1>*Above rates guaranteed to remai=
n level for 10 years.</FONT></P><P style=3D"MARGIN-TOP: -20px; MARGIN-LEFT=
: 50px; MARGIN-RIGHT: 50px" align=3Dcenter><FONT face=3D"Verdana, Arial, H=
elvetica, sans-serif" size=3D1>Rates based on male preferred class 1 non-s=
moker.</FONT></P><P style=3D"MARGIN-TOP: -20px; MARGIN-LEFT: 50px; MARGIN-=
RIGHT: 50px" align=3Dcenter><FONT face=3D"Verdana, Arial, Helvetica, sans-=
serif" size=3D1>Policies are guaranteed renewable to age 95.</FONT></P><P =
style=3D"MARGIN-TOP: -20px; MARGIN-LEFT: 50px; MARGIN-RIGHT: 50px" align=3D=
center><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D1>Polic=
ies with 15, 20, 25 and 30 year level premiums also available.</FONT></P><=
P style=3D"MARGIN-TOP: -20px; MARGIN-LEFT: 50px; MARGIN-RIGHT: 50px" align=
=3Dcenter>&nbsp;</P><P align=3Dcenter><B><FONT face=3D"Arial, Helvetica, s=
ans-serif" color=3D#666666 size=3D4>Attention All Smokers,<BR>you may qual=
ify for special reduced smoker rates!</FONT></B></P><P style=3D"MARGIN-BOT=
TOM: 5px" align=3Dcenter><FONT face=3DArial size=3D2>Universal Life, Secon=
d-to-Die and Estate Planning products also provided.</FONT></P></TD></TR><=
TR><TD colSpan=3D2><DIV align=3Dcenter><CENTER><TABLE height=3D285 cellSpa=
cing=3D0 cellPadding=3D2 width=3D500 border=3D0><TBODY><TR bgcolor=3D#0000=
00><TD vAlign=3Dtop colSpan=3D2 height=3D40><P style=3D"MARGIN-TOP: 10px; =
MARGIN-LEFT: 5px" align=3Dleft><FONT face=3D"Verdana, Arial, Helvetica, sa=
ns-serif" color=3D#ffffff size=3D2><B>Submit This Form for a FREE Term Ins=
urance Quote!</B></FONT></P></TD></TR><TR><TD align=3Dleft width=3D232 bgC=
olor=3D#3974AE><P style=3D"MARGIN-LEFT: 5px"><B><FONT face=3D"Verdana, Ari=
al, Helvetica, sans-serif" size=3D2>Name Insured</FONT>:</B></P></TD><TD a=
lign=3Dleft width=3D260 bgColor=3D#3974AE><P style=3D"MARGIN-TOP: 3px; MAR=
GIN-BOTTOM: 3px"><INPUT size=3D25 name=3DNAME></P></TD></TR><TR><TD align=3D=
left><P style=3D"MARGIN-LEFT: 5px"><B><FONT face=3D"Verdana, Arial, Helvet=
ica, sans-serif" size=3D2>Amount of Coverage:</FONT></B></P></TD><TD align=
=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><SELECT size=3D1 =
name=3DCOVERAGE> <OPTION value=3D$500,000 selected>$500,000 <OPTION value=3D=
$300,000>$300,000 <OPTION value=3D$400,000>$400,000 <OPTION value=3D$500,0=
00>$500,000 <OPTION value=3D$600,000>$600,000 <OPTION value=3D$700,000>$70=
0,000 <OPTION value=3D$800,000>$800,000 <OPTION value=3D$900,000>$900,000 =
<OPTION value=3D$1,000,000>$1,000,000</OPTION> </SELECT></P></TD></TR><TR =
bgcolor=3D#3974AE><TD align=3Dleft><P style=3D"MARGIN-LEFT: 5px"><B><FONT =
face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>Date of Birth:</FO=
NT></B></P></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTO=
M: 3px; MARGIN-RIGHT: -30px"><FONT face=3D"Verdana, Arial, Helvetica, sans=
-serif" size=3D2>Month</FONT> <SELECT name=3DMONTH2> <OPTION value=3D01 se=
lected>01 <OPTION value=3D02>02 <OPTION value=3D03>03 <OPTION value=3D04>0=
4 <OPTION value=3D05>05 <OPTION value=3D06>06 <OPTION value=3D07>07 <OPTIO=
N value=3D08>08 <OPTION value=3D09>09 <OPTION value=3D10>10 <OPTION value=3D=
11>11 <OPTION value=3D12>12</OPTION> </SELECT> &nbsp;<FONT face=3D"Verdana=
, Arial, Helvetica, sans-serif" size=3D2>Day</FONT> <SELECT name=3DDAY2> <=
OPTION value=3D01 selected>01 <OPTION value=3D02>02 <OPTION value=3D03>03 =
<OPTION value=3D04>04 <OPTION value=3D05>05 <OPTION value=3D06>06 <OPTION =
value=3D07>07 <OPTION value=3D08>08 <OPTION value=3D09>09 <OPTION value=3D=
10>10 <OPTION value=3D11>11 <OPTION value=3D12>12 <OPTION value=3D13>13 <O=
PTION value=3D14>14 <OPTION value=3D15>15 <OPTION value=3D16>16 <OPTION va=
lue=3D17>17 <OPTION value=3D18>18 <OPTION value=3D19>19 <OPTION value=3D20=
>20 <OPTION value=3D21>21 <OPTION value=3D22>22 <OPTION value=3D23>23 <OPT=
ION value=3D24>24 <OPTION value=3D25>25 <OPTION value=3D26>26 <OPTION valu=
e=3D27>27 <OPTION value=3D28>28 <OPTION value=3D29>29 <OPTION value=3D30>3=
0 <OPTION value=3D31>31</OPTION> </SELECT> <FONT face=3D"Verdana, Arial, H=
elvetica, sans-serif" size=3D2>Year</FONT><FONT face=3D"Verdana, Arial, He=
lvetica, sans-serif" color=3D#000000 size=3D1> <SELECT name=3Dyear> <OPTIO=
N value=3D"">Year <OPTION value=3DXX selected>Year</OPTION> <OPTION value=3D=
10>1910</OPTION> <OPTION value=3D11>1911</OPTION> <OPTION value=3D12>1912<=
/OPTION> <OPTION value=3D13>1913</OPTION> <OPTION value=3D14>1914</OPTION>=
 <OPTION value=3D15>1915</OPTION> <OPTION value=3D16>1916</OPTION> <OPTION=
 value=3D17>1917</OPTION> <OPTION value=3D18>1918</OPTION> <OPTION value=3D=
19>1919</OPTION> <OPTION value=3D20>1920</OPTION> <OPTION value=3D21>1921<=
/OPTION> <OPTION value=3D22>1922</OPTION> <OPTION value=3D23>1923</OPTION>=
 <OPTION value=3D24>1924</OPTION> <OPTION value=3D25>1925</OPTION> <OPTION=
 value=3D26>1926</OPTION> <OPTION value=3D27>1927</OPTION> <OPTION value=3D=
28>1928</OPTION> <OPTION value=3D29>1929</OPTION> <OPTION value=3D30>1930<=
/OPTION> <OPTION value=3D31>1931</OPTION> <OPTION value=3D32>1932</OPTION>=
 <OPTION value=3D33>1933</OPTION> <OPTION value=3D34>1934</OPTION> <OPTION=
 value=3D35>1935</OPTION> <OPTION value=3D36>1936</OPTION> <OPTION value=3D=
37>1937</OPTION> <OPTION value=3D38>1938</OPTION> <OPTION value=3D39>1939<=
/OPTION> <OPTION value=3D40>1940</OPTION> <OPTION value=3D41>1941</OPTION>=
 <OPTION value=3D42>1942</OPTION> <OPTION value=3D43>1943</OPTION> <OPTION=
 value=3D44>1944</OPTION> <OPTION value=3D45>1945</OPTION> <OPTION value=3D=
46>1946</OPTION> <OPTION value=3D47>1947</OPTION> <OPTION value=3D48>1948<=
/OPTION> <OPTION value=3D49>1949</OPTION> <OPTION value=3D50>1950</OPTION>=
 <OPTION value=3D51>1951</OPTION> <OPTION value=3D52>1952</OPTION> <OPTION=
 value=3D53>1953</OPTION> <OPTION value=3D54>1954</OPTION> <OPTION value=3D=
55>1955</OPTION> <OPTION value=3D56>1956</OPTION> <OPTION value=3D57>1957<=
/OPTION> <OPTION value=3D58>1958</OPTION> <OPTION value=3D59>1959</OPTION>=
 <OPTION value=3D60>1960</OPTION> <OPTION value=3D61>1961</OPTION> <OPTION=
 value=3D62>1962</OPTION> <OPTION value=3D63>1963</OPTION> <OPTION value=3D=
64>1964</OPTION> <OPTION value=3D65>1965</OPTION> <OPTION value=3D66>1966<=
/OPTION> <OPTION value=3D67>1967</OPTION> <OPTION value=3D68>1968</OPTION>=
 <OPTION value=3D69>1969</OPTION> <OPTION value=3D70>1970</OPTION> <OPTION=
 value=3D71>1971</OPTION> <OPTION value=3D72>1972</OPTION> <OPTION value=3D=
73>1973</OPTION> <OPTION value=3D74>1974</OPTION> <OPTION value=3D75>1975<=
/OPTION> <OPTION value=3D76>1976</OPTION> <OPTION value=3D77>1977</OPTION>=
 <OPTION value=3D78>1978</OPTION> <OPTION value=3D79>1979</OPTION> <OPTION=
 value=3D80>1980</OPTION> <OPTION value=3D81>1981</OPTION> <OPTION value=3D=
82>1982</OPTION> <OPTION value=3D83>1983</OPTION> <OPTION value=3D84>1984<=
/OPTION> <OPTION value=3D85>1985</OPTION> <OPTION value=3D86>1986</OPTION>=
 <OPTION value=3D87>1987</OPTION> <OPTION value=3D88>1988</OPTION> <OPTION=
 value=3D89>1989</OPTION> <OPTION value=3D90>1990</OPTION> <OPTION value=3D=
91>1991</OPTION> <OPTION value=3D92>1992</OPTION> <OPTION value=3D93>1993<=
/OPTION> <OPTION value=3D94>1994</OPTION> <OPTION value=3D95>1995</OPTION>=
 <OPTION value=3D96>1996</OPTION> <OPTION value=3D97>1997</OPTION> <OPTION=
 value=3D98>1998</OPTION> <OPTION value=3D99>1999</OPTION> <OPTION value=3D=
00>2000</OPTION> </SELECT></FONT></P></TD></TR><TR><TD align=3Dleft><P sty=
le=3D"MARGIN-LEFT: 5px"><B><FONT face=3D"Verdana, Arial, Helvetica, sans-s=
erif" size=3D2>Sex:</FONT></B></P></TD><TD align=3Dleft><P style=3D"MARGIN=
-TOP: 3px; MARGIN-BOTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sa=
ns-serif" size=3D2>Male</FONT> <INPUT type=3Dradio value=3Dmale name=3DSEX=
1> <FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>Female</F=
ONT> <INPUT type=3Dradio value=3Dfemale name=3DSEX1></P></TD></TR><TR bgco=
lor=3D#3974AE><TD align=3Dleft><DIV align=3Dleft><P style=3D"MARGIN-LEFT: =
5px"><B><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>Heig=
ht:</FONT></B></P></DIV></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px;=
 MARGIN-BOTTOM: 3px"><SELECT name=3Dheightft> <OPTION value=3D"" selected>=
Feet <OPTION value=3D3>3 Feet</OPTION> <OPTION value=3D4>4 Feet</OPTION> <=
OPTION value=3D5>5 Feet</OPTION> <OPTION value=3D6>6 Feet</OPTION> <OPTION=
 value=3D7>7 Feet</OPTION> <OPTION value=3D8>8 Feet</OPTION> </SELECT> <SE=
LECT name=3Dheightin> <OPTION value=3D"" selected>Inches <OPTION value=3D0=
>0 Inches</OPTION> <OPTION value=3D1>1 Inches</OPTION> <OPTION value=3D2>2=
 Inches</OPTION> <OPTION value=3D3>3 Inches</OPTION> <OPTION value=3D4>4 I=
nches</OPTION> <OPTION value=3D5>5 Inches</OPTION> <OPTION value=3D6>6 Inc=
hes</OPTION> <OPTION value=3D7>7 Inches</OPTION> <OPTION value=3D8>8 Inche=
s</OPTION> <OPTION value=3D9>9 Inches</OPTION> <OPTION value=3D10>10 Inche=
s</OPTION> <OPTION value=3D11>11 Inches</OPTION> </SELECT></P></TD></TR><T=
R><TD align=3Dleft><DIV align=3Dleft><P style=3D"MARGIN-LEFT: 5px"><B><FON=
T face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>Weight:</FONT></=
B></P></DIV></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTT=
OM: 3px"><SELECT name=3Dweight> <OPTION value=3D"" selected>Please Select =
Your Weight</OPTION> <OPTION value=3D79>Under 80 lbs.</OPTION> <OPTION val=
ue=3D80>80 lbs.</OPTION> <OPTION value=3D81>81 lbs.</OPTION> <OPTION value=
=3D82>82 lbs.</OPTION> <OPTION value=3D83>83 lbs.</OPTION> <OPTION value=3D=
84>84 lbs.</OPTION> <OPTION value=3D85>85 lbs.</OPTION> <OPTION value=3D86=
>86 lbs.</OPTION> <OPTION value=3D87>87 lbs.</OPTION> <OPTION value=3D88>8=
8 lbs.</OPTION> <OPTION value=3D89>89 lbs.</OPTION> <OPTION value=3D90>90 =
lbs.</OPTION> <OPTION value=3D91>91 lbs.</OPTION> <OPTION value=3D92>92 lb=
s.</OPTION> <OPTION value=3D93>93 lbs.</OPTION> <OPTION value=3D94>94 lbs.=
</OPTION> <OPTION value=3D95>95 lbs.</OPTION> <OPTION value=3D96>96 lbs.</=
OPTION> <OPTION value=3D97>97 lbs.</OPTION> <OPTION value=3D98>98 lbs.</OP=
TION> <OPTION value=3D99>99 lbs.</OPTION> <OPTION value=3D100>100 lbs.</OP=
TION> <OPTION value=3D101>101 lbs.</OPTION> <OPTION value=3D102>102 lbs.</=
OPTION> <OPTION value=3D103>103 lbs.</OPTION> <OPTION value=3D104>104 lbs.=
</OPTION> <OPTION value=3D105>105 lbs.</OPTION> <OPTION value=3D106>106 lb=
s.</OPTION> <OPTION value=3D107>107 lbs.</OPTION> <OPTION value=3D108>108 =
lbs.</OPTION> <OPTION value=3D109>109 lbs.</OPTION> <OPTION value=3D110>11=
0 lbs.</OPTION> <OPTION value=3D111>111 lbs.</OPTION> <OPTION value=3D112>=
112 lbs.</OPTION> <OPTION value=3D113>113 lbs.</OPTION> <OPTION value=3D11=
4>114 lbs.</OPTION> <OPTION value=3D115>115 lbs.</OPTION> <OPTION value=3D=
116>116 lbs.</OPTION> <OPTION value=3D117>117 lbs.</OPTION> <OPTION value=3D=
118>118 lbs.</OPTION> <OPTION value=3D119>119 lbs.</OPTION> <OPTION value=3D=
120>120 lbs.</OPTION> <OPTION value=3D121>121 lbs.</OPTION> <OPTION value=3D=
122>122 lbs.</OPTION> <OPTION value=3D123>123 lbs.</OPTION> <OPTION value=3D=
124>124 lbs.</OPTION> <OPTION value=3D125>125 lbs.</OPTION> <OPTION value=3D=
126>126 lbs.</OPTION> <OPTION value=3D127>127 lbs.</OPTION> <OPTION value=3D=
128>128 lbs.</OPTION> <OPTION value=3D129>129 lbs.</OPTION> <OPTION value=3D=
130>130 lbs.</OPTION> <OPTION value=3D131>131 lbs.</OPTION> <OPTION value=3D=
132>132 lbs.</OPTION> <OPTION value=3D133>133 lbs.</OPTION> <OPTION value=3D=
134>134 lbs.</OPTION> <OPTION value=3D135>135 lbs.</OPTION> <OPTION value=3D=
136>136 lbs.</OPTION> <OPTION value=3D137>137 lbs.</OPTION> <OPTION value=3D=
138>138 lbs.</OPTION> <OPTION value=3D139>139 lbs.</OPTION> <OPTION value=3D=
140>140 lbs.</OPTION> <OPTION value=3D141>141 lbs.</OPTION> <OPTION value=3D=
142>142 lbs.</OPTION> <OPTION value=3D143>143 lbs.</OPTION> <OPTION value=3D=
144>144 lbs.</OPTION> <OPTION value=3D145>145 lbs.</OPTION> <OPTION value=3D=
146>146 lbs.</OPTION> <OPTION value=3D147>147 lbs.</OPTION> <OPTION value=3D=
148>148 lbs.</OPTION> <OPTION value=3D149>149 lbs.</OPTION> <OPTION value=3D=
150>150 lbs.</OPTION> <OPTION value=3D151>151 lbs.</OPTION> <OPTION value=3D=
152>152 lbs.</OPTION> <OPTION value=3D153>153 lbs.</OPTION> <OPTION value=3D=
154>154 lbs.</OPTION> <OPTION value=3D155>155 lbs.</OPTION> <OPTION value=3D=
156>156 lbs.</OPTION> <OPTION value=3D157>157 lbs.</OPTION> <OPTION value=3D=
158>158 lbs.</OPTION> <OPTION value=3D159>159 lbs.</OPTION> <OPTION value=3D=
160>160 lbs.</OPTION> <OPTION value=3D161>161 lbs.</OPTION> <OPTION value=3D=
162>162 lbs.</OPTION> <OPTION value=3D163>163 lbs.</OPTION> <OPTION value=3D=
164>164 lbs.</OPTION> <OPTION value=3D165>165 lbs.</OPTION> <OPTION value=3D=
166>166 lbs.</OPTION> <OPTION value=3D167>167 lbs.</OPTION> <OPTION value=3D=
168>168 lbs.</OPTION> <OPTION value=3D169>169 lbs.</OPTION> <OPTION value=3D=
170>170 lbs.</OPTION> <OPTION value=3D171>171 lbs.</OPTION> <OPTION value=3D=
172>172 lbs.</OPTION> <OPTION value=3D173>173 lbs.</OPTION> <OPTION value=3D=
174>174 lbs.</OPTION> <OPTION value=3D175>175 lbs.</OPTION> <OPTION value=3D=
176>176 lbs.</OPTION> <OPTION value=3D177>177 lbs.</OPTION> <OPTION value=3D=
178>178 lbs.</OPTION> <OPTION value=3D179>179 lbs.</OPTION> <OPTION value=3D=
180>180 lbs.</OPTION> <OPTION value=3D181>181 lbs.</OPTION> <OPTION value=3D=
182>182 lbs.</OPTION> <OPTION value=3D183>183 lbs.</OPTION> <OPTION value=3D=
184>184 lbs.</OPTION> <OPTION value=3D185>185 lbs.</OPTION> <OPTION value=3D=
186>186 lbs.</OPTION> <OPTION value=3D187>187 lbs.</OPTION> <OPTION value=3D=
188>188 lbs.</OPTION> <OPTION value=3D189>189 lbs.</OPTION> <OPTION value=3D=
190>190 lbs.</OPTION> <OPTION value=3D191>191 lbs.</OPTION> <OPTION value=3D=
192>192 lbs.</OPTION> <OPTION value=3D193>193 lbs.</OPTION> <OPTION value=3D=
194>194 lbs.</OPTION> <OPTION value=3D195>195 lbs.</OPTION> <OPTION value=3D=
196>196 lbs.</OPTION> <OPTION value=3D197>197 lbs.</OPTION> <OPTION value=3D=
198>198 lbs.</OPTION> <OPTION value=3D199>199 lbs.</OPTION> <OPTION value=3D=
200>200 lbs.</OPTION> <OPTION value=3D201>201 lbs.</OPTION> <OPTION value=3D=
202>202 lbs.</OPTION> <OPTION value=3D203>203 lbs.</OPTION> <OPTION value=3D=
204>204 lbs.</OPTION> <OPTION value=3D205>205 lbs.</OPTION> <OPTION value=3D=
206>206 lbs.</OPTION> <OPTION value=3D207>207 lbs.</OPTION> <OPTION value=3D=
208>208 lbs.</OPTION> <OPTION value=3D209>209 lbs.</OPTION> <OPTION value=3D=
210>210 lbs.</OPTION> <OPTION value=3D211>211 lbs.</OPTION> <OPTION value=3D=
212>212 lbs.</OPTION> <OPTION value=3D213>213 lbs.</OPTION> <OPTION value=3D=
214>214 lbs.</OPTION> <OPTION value=3D215>215 lbs.</OPTION> <OPTION value=3D=
216>216 lbs.</OPTION> <OPTION value=3D217>217 lbs.</OPTION> <OPTION value=3D=
218>218 lbs.</OPTION> <OPTION value=3D219>219 lbs.</OPTION> <OPTION value=3D=
220>220 lbs.</OPTION> <OPTION value=3D221>221 lbs.</OPTION> <OPTION value=3D=
222>222 lbs.</OPTION> <OPTION value=3D223>223 lbs.</OPTION> <OPTION value=3D=
224>224 lbs.</OPTION> <OPTION value=3D225>225 lbs.</OPTION> <OPTION value=3D=
226>226 lbs.</OPTION> <OPTION value=3D227>227 lbs.</OPTION> <OPTION value=3D=
228>228 lbs.</OPTION> <OPTION value=3D229>229 lbs.</OPTION> <OPTION value=3D=
230>230 lbs.</OPTION> <OPTION value=3D231>231 lbs.</OPTION> <OPTION value=3D=
232>232 lbs.</OPTION> <OPTION value=3D233>233 lbs.</OPTION> <OPTION value=3D=
234>234 lbs.</OPTION> <OPTION value=3D235>235 lbs.</OPTION> <OPTION value=3D=
236>236 lbs.</OPTION> <OPTION value=3D237>237 lbs.</OPTION> <OPTION value=3D=
238>238 lbs.</OPTION> <OPTION value=3D239>239 lbs.</OPTION> <OPTION value=3D=
240>240 lbs.</OPTION> <OPTION value=3D241>241 lbs.</OPTION> <OPTION value=3D=
242>242 lbs.</OPTION> <OPTION value=3D243>243 lbs.</OPTION> <OPTION value=3D=
244>244 lbs.</OPTION> <OPTION value=3D245>245 lbs.</OPTION> <OPTION value=3D=
246>246 lbs.</OPTION> <OPTION value=3D247>247 lbs.</OPTION> <OPTION value=3D=
248>248 lbs.</OPTION> <OPTION value=3D249>249 lbs.</OPTION> <OPTION value=3D=
250>250 lbs.</OPTION> <OPTION value=3D251>251 lbs.</OPTION> <OPTION value=3D=
252>252 lbs.</OPTION> <OPTION value=3D253>253 lbs.</OPTION> <OPTION value=3D=
254>254 lbs.</OPTION> <OPTION value=3D255>255 lbs.</OPTION> <OPTION value=3D=
256>256 lbs.</OPTION> <OPTION value=3D257>257 lbs.</OPTION> <OPTION value=3D=
258>258 lbs.</OPTION> <OPTION value=3D259>259 lbs.</OPTION> <OPTION value=3D=
260>260 lbs.</OPTION> <OPTION value=3D261>261 lbs.</OPTION> <OPTION value=3D=
262>262 lbs.</OPTION> <OPTION value=3D263>263 lbs.</OPTION> <OPTION value=3D=
264>264 lbs.</OPTION> <OPTION value=3D265>265 lbs.</OPTION> <OPTION value=3D=
266>266 lbs.</OPTION> <OPTION value=3D267>267 lbs.</OPTION> <OPTION value=3D=
268>268 lbs.</OPTION> <OPTION value=3D269>269 lbs.</OPTION> <OPTION value=3D=
270>270 lbs.</OPTION> <OPTION value=3D271>271 lbs.</OPTION> <OPTION value=3D=
272>272 lbs.</OPTION> <OPTION value=3D273>273 lbs.</OPTION> <OPTION value=3D=
274>274 lbs.</OPTION> <OPTION value=3D275>275 lbs.</OPTION> <OPTION value=3D=
276>276 lbs.</OPTION> <OPTION value=3D277>277 lbs.</OPTION> <OPTION value=3D=
278>278 lbs.</OPTION> <OPTION value=3D279>279 lbs.</OPTION> <OPTION value=3D=
280>280 lbs.</OPTION> <OPTION value=3D281>281 lbs.</OPTION> <OPTION value=3D=
282>282 lbs.</OPTION> <OPTION value=3D283>283 lbs.</OPTION> <OPTION value=3D=
284>284 lbs.</OPTION> <OPTION value=3D285>285 lbs.</OPTION> <OPTION value=3D=
286>286 lbs.</OPTION> <OPTION value=3D287>287 lbs.</OPTION> <OPTION value=3D=
288>288 lbs.</OPTION> <OPTION value=3D289>289 lbs.</OPTION> <OPTION value=3D=
290>290 lbs.</OPTION> <OPTION value=3D291>291 lbs.</OPTION> <OPTION value=3D=
292>292 lbs.</OPTION> <OPTION value=3D293>293 lbs.</OPTION> <OPTION value=3D=
294>294 lbs.</OPTION> <OPTION value=3D295>295 lbs.</OPTION> <OPTION value=3D=
296>296 lbs.</OPTION> <OPTION value=3D297>297 lbs.</OPTION> <OPTION value=3D=
298>298 lbs.</OPTION> <OPTION value=3D299>299 lbs.</OPTION> <OPTION value=3D=
300>300 lbs.</OPTION> <OPTION value=3D301>301 lbs.</OPTION> <OPTION value=3D=
302>302 lbs.</OPTION> <OPTION value=3D303>303 lbs.</OPTION> <OPTION value=3D=
304>304 lbs.</OPTION> <OPTION value=3D305>305 lbs.</OPTION> <OPTION value=3D=
306>306 lbs.</OPTION> <OPTION value=3D307>307 lbs.</OPTION> <OPTION value=3D=
308>308 lbs.</OPTION> <OPTION value=3D309>309 lbs.</OPTION> <OPTION value=3D=
310>310 lbs.</OPTION> <OPTION value=3D311>311 lbs.</OPTION> <OPTION value=3D=
312>312 lbs.</OPTION> <OPTION value=3D313>313 lbs.</OPTION> <OPTION value=3D=
314>314 lbs.</OPTION> <OPTION value=3D315>315 lbs.</OPTION> <OPTION value=3D=
316>316 lbs.</OPTION> <OPTION value=3D317>317 lbs.</OPTION> <OPTION value=3D=
318>318 lbs.</OPTION> <OPTION value=3D319>319 lbs.</OPTION> <OPTION value=3D=
320>320 lbs.</OPTION> <OPTION value=3D321>321 lbs.</OPTION> <OPTION value=3D=
322>322 lbs.</OPTION> <OPTION value=3D323>323 lbs.</OPTION> <OPTION value=3D=
324>324 lbs.</OPTION> <OPTION value=3D325>325 lbs.</OPTION> <OPTION value=3D=
326>326 lbs.</OPTION> <OPTION value=3D327>327 lbs.</OPTION> <OPTION value=3D=
328>328 lbs.</OPTION> <OPTION value=3D329>329 lbs.</OPTION> <OPTION value=3D=
330>330 lbs.</OPTION> <OPTION value=3D331>331 lbs.</OPTION> <OPTION value=3D=
332>332 lbs.</OPTION> <OPTION value=3D333>333 lbs.</OPTION> <OPTION value=3D=
334>334 lbs.</OPTION> <OPTION value=3D335>335 lbs.</OPTION> <OPTION value=3D=
336>336 lbs.</OPTION> <OPTION value=3D337>337 lbs.</OPTION> <OPTION value=3D=
338>338 lbs.</OPTION> <OPTION value=3D339>339 lbs.</OPTION> <OPTION value=3D=
340>340 lbs.</OPTION> <OPTION value=3D341>341 lbs.</OPTION> <OPTION value=3D=
342>342 lbs.</OPTION> <OPTION value=3D343>343 lbs.</OPTION> <OPTION value=3D=
344>344 lbs.</OPTION> <OPTION value=3D345>345 lbs.</OPTION> <OPTION value=3D=
346>346 lbs.</OPTION> <OPTION value=3D347>347 lbs.</OPTION> <OPTION value=3D=
348>348 lbs.</OPTION> <OPTION value=3D349>349 lbs.</OPTION> <OPTION value=3D=
350>350 lbs.</OPTION> <OPTION value=3D351>351 lbs.</OPTION> <OPTION value=3D=
352>352 lbs.</OPTION> <OPTION value=3D353>353 lbs.</OPTION> <OPTION value=3D=
354>354 lbs.</OPTION> <OPTION value=3D355>355 lbs.</OPTION> <OPTION value=3D=
356>356 lbs.</OPTION> <OPTION value=3D357>357 lbs.</OPTION> <OPTION value=3D=
358>358 lbs.</OPTION> <OPTION value=3D359>359 lbs.</OPTION> <OPTION value=3D=
360>360 lbs.</OPTION> <OPTION value=3D361>361 lbs.</OPTION> <OPTION value=3D=
362>362 lbs.</OPTION> <OPTION value=3D363>363 lbs.</OPTION> <OPTION value=3D=
364>364 lbs.</OPTION> <OPTION value=3D365>365 lbs.</OPTION> <OPTION value=3D=
366>366 lbs.</OPTION> <OPTION value=3D367>367 lbs.</OPTION> <OPTION value=3D=
368>368 lbs.</OPTION> <OPTION value=3D369>369 lbs.</OPTION> <OPTION value=3D=
370>370 lbs.</OPTION> <OPTION value=3D371>371 lbs.</OPTION> <OPTION value=3D=
372>372 lbs.</OPTION> <OPTION value=3D373>373 lbs.</OPTION> <OPTION value=3D=
374>374 lbs.</OPTION> <OPTION value=3D375>375 lbs.</OPTION> <OPTION value=3D=
376>376 lbs.</OPTION> <OPTION value=3D377>377 lbs.</OPTION> <OPTION value=3D=
378>378 lbs.</OPTION> <OPTION value=3D379>379 lbs.</OPTION> <OPTION value=3D=
380>380 lbs.</OPTION> <OPTION value=3D381>Over 380 lbs.</OPTION> </SELECT>=
</P></TD></TR><TR bgcolor=3D#3974AE><TD align=3Dleft><P style=3D"MARGIN-LE=
FT: 5px"><B><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>=
Occupation:</FONT></B></P></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3p=
x; MARGIN-BOTTOM: 3px"><INPUT size=3D37 name=3DOCCUPATION1></P></TD></TR><=
TR><TD align=3Dleft colSpan=3D2><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM=
: 3px; MARGIN-LEFT: 5px"><B><FONT face=3D"Verdana, Arial, Helvetica, sans-=
serif" size=3D2>Have You Ever Had:</FONT></B></P></TD></TR><TR><TD align=3D=
left><P style=3D"MARGIN-LEFT: 5px">&nbsp;&nbsp;&nbsp;&nbsp; <FONT face=3D"=
Verdana, Arial, Helvetica, sans-serif" size=3D2>High Blood Pressure:</FONT=
>:</P></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3p=
x"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>Yes</FONT=
> <INPUT type=3Dradio value=3Dyes name=3DHIGH_BLOOD_PRESSURE1> <FONT face=3D=
"Verdana, Arial, Helvetica, sans-serif" size=3D2>No</FONT> <INPUT type=3Dr=
adio CHECKED value=3Dno name=3DHIGH_BLOOD_PRESSURE1></P></TD></TR><TR><TD =
align=3Dleft><P style=3D"MARGIN-LEFT: 5px">&nbsp;&nbsp;&nbsp;&nbsp; <FONT =
face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>Heart Attack or St=
roke:</FONT></P></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-=
BOTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2=
>Yes</FONT> <INPUT type=3Dradio value=3Dyes name=3DHEART_ATTACK_OR_STROKE1=
> <FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>No</FONT> =
<INPUT type=3Dradio CHECKED value=3Dno name=3DHEART_ATTACK_OR_STROKE1></P>=
</TD></TR><TR><TD align=3Dleft><P style=3D"MARGIN-LEFT: 5px">&nbsp;&nbsp;&=
nbsp;&nbsp; <FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D2>=
Cancer:</FONT></P></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGI=
N-BOTTOM: 3px"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=3D=
2>Yes</FONT> <INPUT type=3Dradio value=3Dyes name=3DCANCER1> <FONT face=3D=
"Verdana, Arial, Helvetica, sans-serif" size=3D2>No</FONT> <INPUT type=3Dr=
adio CHECKED value=3Dno name=3DCANCER1></P></TD></TR><TR><TD align=3Dleft>=
<P style=3D"MARGIN-LEFT: 5px">&nbsp;&nbsp;&nbsp;&nbsp; <FONT face=3D"Verda=
na, Arial, Helvetica, sans-serif" size=3D2>Diabetes:</FONT></P></TD><TD al=
ign=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><FONT face=3D"=
Verdana, Arial, Helvetica, sans-serif" size=3D2>Yes</FONT> <INPUT type=3Dr=
adio value=3Dyes name=3DDIABETES1> <FONT face=3D"Verdana, Arial, Helvetica=
, sans-serif" size=3D2>No</FONT> <INPUT type=3Dradio CHECKED value=3Dno na=
me=3DDIABETES1></P></TD></TR><TR><TD align=3Dleft><P style=3D"MARGIN-LEFT:=
 5px; MARGIN-RIGHT: 5px">&nbsp; &nbsp;&nbsp; <FONT face=3D"Verdana, Arial,=
 Helvetica, sans-serif" size=3D2>Smoked Within the</FONT></P><P style=3D"M=
ARGIN: -23px 5px 3px 22px">&nbsp;<FONT face=3D"Verdana, Arial, Helvetica, =
sans-serif" size=3D2>Last 12 months:</FONT></P></TD><TD align=3Dleft><P st=
yle=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><FONT face=3D"Verdana, Arial, =
Helvetica, sans-serif" size=3D2>Yes</FONT> <INPUT type=3Dradio value=3Dyes=
 name=3DSMOKE_LAST_12_MO1> <FONT face=3D"Verdana, Arial, Helvetica, sans-s=
erif" size=3D2>No</FONT> <INPUT type=3Dradio CHECKED value=3Dno name=3DSMO=
KE_LAST_12_MO1></P></TD></TR><TR bgcolor=3D#3974AE><TD align=3Dleft><P sty=
le=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px; MARGIN-LEFT: 5px"><FONT face=3D=
"Verdana, Arial, Helvetica, sans-serif" size=3D2><B>Person Completing Requ=
est:</B>&nbsp;</FONT></P></TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px=
; MARGIN-BOTTOM: 3px"><INPUT size=3D39 value=3D" - Same As Above -" name=3D=
PERSON_COMPLETING_REQUEST></P></TD></TR><TR><TD align=3Dleft><P style=3D"M=
ARGIN-LEFT: 5px"><FONT face=3D"Verdana, Arial, Helvetica, sans-serif" size=
=3D2><B>Mailing Address:</B></FONT><P style=3D"MARGIN-LEFT: 5px">&nbsp;</P=
><P style=3D"MARGIN-LEFT: 5px">&nbsp;</P></TD><TD align=3Dleft><P style=3D=
"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><TEXTAREA name=3DSTREET rows=3D4 col=
s=3D35></TEXTAREA></P></TD></TR><TR bgcolor=3D#3974AE><TD align=3Dleft><P =
style=3D"MARGIN-LEFT: 5px"><FONT face=3D"Verdana, Arial, Helvetica, sans-s=
erif" size=3D2><B>City:</B></FONT></P></TD><TD align=3Dleft><P style=3D"MA=
RGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><INPUT size=3D28 name=3DCITY> &nbsp;</P=
></TD></TR><TR><TD align=3Dleft><P style=3D"MARGIN-LEFT: 5px"><FONT face=3D=
"Verdana, Arial, Helvetica, sans-serif" size=3D2><B>State:</B></FONT></P><=
/TD><TD align=3Dleft><P style=3D"MARGIN-TOP: 3px; MARGIN-BOTTOM: 3px"><FON=
T color=3D#000000><SELECT name=3Dstate> <OPTION value=3D"" selected>Select=
 A State</OPTION> <OPTION value=3DAL>Alabama</OPTION> <OPTION value=3DAK>A=
laska</OPTION> <OPTION value=3DAZ>Arizona</OPTION> <OPTION value=3DAR>Arka=
nsas</OPTION> <OPTION value=3DCA>California</OPTION> <OPTION value=3DCO>Co=
lorado</OPTION> <OPTION value=3DCT>Connecticut</OPTION> <OPTION value=3DDE=
>Delaware</OPTION> <OPTION value=3DDC>Dist. of Columbia</OPTION> <OPTION v=
alue=3DFL>Florida</OPTION> <OPTION value=3DGA>Georgia</OPTION> <OPTION val=
ue=3DHI>Hawaii</OPTION> <OPTION value=3DID>Idaho</OPTION> <OPTION value=3D=
IL>Illinois</OPTION> <OPTION value=3DIN>Indiana</OPTION> <OPTION value=3DI=
A>Iowa</OPTION> <OPTION value=3DKS>Kansas</OPTION> <OPTION value=3DKY>Kent=
ucky</OPTION> <OPTION value=3DLA>Louisiana</OPTION> <OPTION value=3DME>Mai=
ne</OPTION> <OPTION value=3DMD>Maryland</OPTION> <OPTION value=3DMA>Massac=
husetts</OPTION> <OPTION value=3DMI>Michigan</OPTION> <OPTION value=3DMN>M=
innesota</OPTION> <OPTION value=3DMS>Mississippi</OPTION> <OPTION value=3D=
MO>Missouri</OPTION> <OPTION value=3DMT>Montana</OPTION> <OPTION value=3DN=
E>Nebraska</OPTION> <OPTION value=3DNV>Nevada</OPTION> <OPTION value=3DNH>=
New Hampshire</OPTION> <OPTION value=3DNJ>NewJersey</OPTION> <OPTION value=
=3DNM>New Mexico</OPTION> <OPTION value=3DNY>New York</OPTION> <OPTION val=
ue=3DNC>North Carolina</OPTION> <OPTION value=3DND>North Dakota</OPTION> <=
OPTION value=3DOH>Ohio</OPTION> <OPTION value=3DOK>Oklahoma</OPTION> <OPTI=
ON value=3DOR>Oregon</OPTION> <OPTION value=3DPA>Pennsylvania</OPTION> <OP=
TION value=3DRI>Rhode Island</OPTION> <OPTION value=3DSC>South Carolina</O=
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