Request Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=200 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <div> <IMG SRC="1e050500.gif" border=0 width="80" height="80" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="WILD PALMS"><B>Home</B></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="About Us"><B>About Us</B></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Request Form"><B>Request Form</B></A></div> <div> <A HREF="id48.htm" TARGET="_top" TITLE="FAQS"><B>FAQS</B></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="Contact Us"><B>Contact Us</B></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="Client Sites"><B>Client Sites</B></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="Cool Links"><B>Cool Links</B></A></div> <bR> <bR> </td> <td valign="top" width="100%" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> WILD PALMS<FONT SIZE="7" COLOR="#006633" FACE="Cezanne" >          </FONT><FONT SIZE="1" COLOR="#000000" FACE="Arial" >                         <IMG SRC="1e180610.gif" border=0 width="128" height="97" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></FONT></div> <div> <I> </I><I>                </I><FONT SIZE="4" COLOR="#663300" FACE="Arial" ><I><B> Global Solutions for a Global Community</B></I></FONT></div> <bR> <bR> <div> <B>Request Form</B></div> <bR> <bR> <div>  <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,LastName,Email,Company,Address1,Address2,City,State,Zip,Phone,Fax,MailingList,[Custom],Comments"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for information from Wild Palms Resources.."><input type="hidden" name="tlx_SendMode" value="2"><input type="hidden" name="tlx_Subject" value="A request form was submitted"><input type="hidden" name="tlx_EmailTo" value="dws@wildpalms.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">First Name:<br> <input type="text" name="FirstName" size="50" maxlength="500"></td> </tr> <tr> <td align="left">Last Name:<br> <input type="text" name="LastName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Company:<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 2:<br> <input type="text" name="Address2" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">State:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Zip:<br> <input type="text" name="Zip" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Fax Number:<br> <input type="text" name="Fax" size="14" maxlength="14"></td> </tr> <tr> <td> <input type="checkbox" name="MailingList" value="yes"> Add me to your mailing list</td> </tr> <tr> <td align="left">Nature of Request:<br> <input type="text" name="[Custom]" size="50" maxlength="300"></td> </tr> <tr> <td align="left">Comments:<br> <textarea name="Comments" rows="5" cols="30"></textarea></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div> _____________________________________________________</div> <bR> <div> <I>This page last updated on:  02/20/2006 </I> <FONT SIZE="2" COLOR="#000000" FACE="Arial" > </FONT><FONT SIZE="4" COLOR="#006633" FACE="Cezanne" >Wild Palms Resource</FONT><FONT SIZE="3" COLOR="#006633" FACE="Cezanne" >s</FONT><FONT SIZE="2" COLOR="#006633" FACE="Arial" > </FONT><FONT SIZE="2" COLOR="#000000" FACE="Arial" ><IMG SRC="0ad0c0d0.gif" border=0 width="12" height="13" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></FONT> - <I>All Rights Reserved</I></div> <bR> </td> </tr></table></body>