<form method="post" action="http://www.emailmeform.com/fid.php?formid=200137" enctype="multipart/form-data" accept-charset="UTF-8">
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<font face="Verdana" size="2" color="#000000"><H3>Order Form for BPAY </H3><P>
<H5>Please enter the following information if you wish to order your books and pay for them by BPAY. </H5><P>We shall email you an invoice once we receive your order and send the books to you once the payment has been cleared by the bank according to the terms on the invoice.
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 <td nowrap><font face="Verdana" size="2" color="#000000">Your Name</font></td>
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<input type="text" name="FieldData0" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Your Email Address</font></td>
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<input type="text" name="FieldData1" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Type of Customer (please click)</font></td>
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<input type=radio name="FieldData2" value="On-line retail customer" id="radio20"><font face="Verdana" size="2" color="#000000"><label for="radio20">On-line retail customer</label></font><br><input type=radio name="FieldData2" value="Book club customer" id="radio21"><font face="Verdana" size="2" color="#000000"><label for="radio21">Book club customer</label></font><br><input type=radio name="FieldData2" value="Dealer(standard trade)" id="radio22"><font face="Verdana" size="2" color="#000000"><label for="radio22">Dealer(standard trade)</label></font><br><input type=radio name="FieldData2" value="Dealer(special terms)" id="radio23"><font face="Verdana" size="2" color="#000000"><label for="radio23">Dealer(special terms)</label></font><br><input type=radio name="FieldData2" value="Contract" id="radio24"><font face="Verdana" size="2" color="#000000"><label for="radio24">Contract</label></font><br> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Organization</font></td>
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<input type="text" name="FieldData3" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Address Line 1</font></td>
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<input type="text" name="FieldData4" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Address Line 2</font></td>
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<input type="text" name="FieldData5" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Town/City/Suburb</font></td>
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<input type="text" name="FieldData6" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">State</font></td>
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<input type="text" name="FieldData7" value="" maxlength="100" size="4"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Postal Code</font></td>
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<input type="text" name="FieldData8" value="" maxlength="100" size="4"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Contact Telephone number</font></td>
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<input type="text" name="FieldData9" value="" maxlength="100" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">How many books do you require?</font></td>
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<input type="text" name="FieldData10" value="" maxlength="100" size="4"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Address if different from above</font></td>
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<textarea name="FieldData11" cols="40" rows="10"></textarea><br> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Additional Information if required</font></td>
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<textarea name="FieldData12" cols="40" rows="10"></textarea><br> <div style="position: absolute; left: 1800px; top: 20px;"><a href="http://www.emailmeform.com">php forms</a></div></td>
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<td colspan="2"><font color="#FFFFFF" face="Verdana" size="2"><b>Image Verification</b></font></td>
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<td style="padding: 2px;" width="10"><img src="http://www.emailmeform.com/turing.php" id="captcha"></td>
<td valign="top"><font color="#000000">Please enter the text from the image</font>   <br><input type="text" name="Turing" value="" maxlength="100" size="10">
 [ <a href="#" onclick=" document.getElementById('captcha').src = document.getElementById('captcha').src + '?' + (new Date()).getMilliseconds()">Refresh Image</a> ] [ <a href="http://www.emailmeform.com/?v=turing&pt=popup" onClick="window.open('http://www.emailmeform.com/?v=turing&pt=popup','_blank','width=400, height=300, left=' + (screen.width-450) + ', top=100');return false;">What's This?</a> ]
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 <td> </td>
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<input type="text" name="hida2" value="" maxlength="100" size="3" style="display : none;">
<input type="submit" class="btn" value="Send email" name="Submit">    <input type="reset" class="btn" value="  Clear form   " name="Clear"></td>
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