{HEADER}
<script language="JavaScript" type="text/javascript">
<!--
function validate ()
{
	if (document.bisform.custom_first_name.value =='' )
	{
		alert ('Please fill First Name Field !');
	}
	else if (document.bisform.custom_last_name.value=='')
	{
		alert ('Please fill Last Name Field !');
	}
	else if (document.bisform.custom_address.value=='')
	{
		alert ('Please fill Address Field !');
	}
	else if (document.bisform.custom_city.value=='')
	{
		alert ('Please fill City Field !');
	}
	else if (document.bisform.custom_state.value=='')
	{
		alert ('Please fill State Field !');
	}
	else if (document.bisform.custom_zipcode.value=='')
	{
		alert ('Please fill Zipcode Field !');
	}
	else if (document.bisform.custom_country.value=='')
	{
		alert ('Please fill Country Field !');
	}
	else if (document.bisform.custom_phone.value=='')
	{
		alert ('Please fill Phone Field !');
	}
		else if (document.bisform.from.value=='')
	{
		alert ('Please fill Email Field !');
	}
	else 
	{
		document.bisform.submit();
	}
}
//-->
</script>
<table width="780" height="80%" border="0" align="center" cellpadding="0" cellspacing="0">
	<tr>
		<td background="img/bg.jpg" valign="top" align="center" class="product-con1">
			<div style="padding: 10px; width: 600px; font-size: 18px; color: #000000;">
 			What does it take for you a WOMAN to start your own business?	<br>
			What challenges will YOU face in taking control of your destiny and opening your own business?</div>
			<div style="padding: 10px; width: 600px; font-size: 16px; color: #000000;">
			Please complete the below form and we will immediately forward a copy of this award winning guide, that has helped WOMEN JUST LIKE YOU OWN THEIR OWN BUSINESS </div>
			<div style="padding: 10px; width: 600px; font-size: 16px; color: red;">
			REGISTER HERE - FREE WOMAN BUSINESS GUIDE
			</div>
			<div align="center" style="width: 400px;">
			<!-- START FORM -->
			<form name="bisform" action="thankyou.php" method="GET" >
			<table>
				<tr>
					<td >First Name: </td>
					<td >
					<input name="custom_first_name" type="text" id="custom_first_name" value="{F_NAME}">
					</td>
				</tr>
				<tr>
					<td>Last Name: </td>
					<td >
					<input name="custom_last_name" type="text" id="custom_last_name" value="{L_NAME}">
					</td>
				</tr>
				<tr>
					<td>Address: </td>
					<td class="product-con1">
					<input type="text" name="custom_address"  value="{ADDRESS}">
					</td>
				</tr>
				<tr>
					<td>City: </td>
					<td class="product-con1">
					<input name="custom_city" type="text" id="custom_city" value="{CITY}">
					</td>
				</tr>
				<tr>
					<td>State: </td>
					<td><select name="custom_state" id="custom_state">
							<option value='' selected>-Select State-
							<option value=AL >Alabama
							<option value=AK >Alaska
							<option value=AS >American Samoa
							<option value=AZ >Arizona
							<option value=AR >Arkansas
							<option value=CA >California
							<option value=CO >Colorado
							<option value=CT >Connecticut
							<option value=DE >Delaware
							<option value=DC >District of Columbia
							<option value=FL >Florida
							<option value=GA >Georgia
							<option value=GU >Guam
							<option value=HI >Hawaii
							<option value=ID >Idaho
							<option value=IL >Illinois
							<option value=IN >Indiana
							<option value=IA >Iowa
							<option value=KS >Kansas
							<option value=KY >Kentucky
							<option value=LA >Louisiana
							<option value=ME >Maine
							<option value=MH >Marshall Islands
							<option value=MD >Maryland
							<option value=MA >Massachusetts
							<option value=MI >Michigan
							<option value=MN >Minnesota
							<option value=MS >Mississippi
							<option value=MO >Missouri
							<option value=MT >Montana
							<option value=NE >Nebraska
							<option value=NV >Nevada
							<option value=NH >New Hampshire
							<option value=NJ >New Jersey
							<option value=NM >New Mexico
							<option value=NY >New York
							<option value=NC >North Carolina
							<option value=ND >North Dakota
							<option value=OH >Ohio
							<option value=OK >Oklahoma
							<option value=OR >Oregon
							<option value=PW >Palau
							<option value=PA >Pennsylvania
							<option value=PR >Puerto Rico
							<option value=RI >Rhode Island
							<option value=SC >South Carolina
							<option value=SD >South Dakota
							<option value=TN >Tennessee
							<option value=TX >Texas
							<option value=TT >Trust Territories
							<option value=UT >Utah
							<option value=VT >Vermont
							<option value=VI >Virgin Islands
							<option value=VA >Virginia
							<option value=WL >Wake Island
							<option value=WA >Washington
							<option value=WV >West Virginia
							<option value=WI >Wisconsin
							<option value=WY >Wyoming
							<option value=Outside of US >Outside of US
							<option value="In Canada">In Canada</select> </td>
				</tr>
				<tr>
					<td>Zip Code:</td>
					<td><input name="custom_zipcode" type="text" id="custom zipcode"> </td>
				</tr>
				<tr>
					<td>Country:</td>
					<td>
						<select name="custom_country" id="custom_country">
							<option value="United States" selected>United States</option>
							<option value="Canada">Canada</option>
							<option value="International">International</option>
						</select>
					</td>
				</tr>
				<tr>
					<td>Phone number:<br>
						i.e. 888-555-3434 <br></td>
					<td ><input name="custom_phone" type="text" id="custom_phone" value="{PHONE}">
					</td>
				</tr>
				<tr>
					<td>Email Address:<br>
						e.g., email@aol.com </td>
					<td ><input name="from" type="text" id="from"  value="{EMAIL}">
						<input type="hidden" name="search_engine" value="{SEARCH_ENGINE}">
						<input type="hidden" name="key_word" value="{KEY_WORD}">
						<input type="hidden" name="surl" value="{URL}">
						<input type="hidden" name="id" value="{ID}">
					</td>
					</td>
				</tr>
				<tr align="center" >
					<td colspan="2" ><input type="button" name="Submit" value="Submit" onClick='validate()'>
					</td>
				</tr>
			</table>
			</form>
			<!-- END FORM -->
			</div>
				<div  align="center" style="padding: 5px; width: 600px; font-size: 12px; color: #000000;">* All fields are required (Note we validate all information, so please double-check each field)<br>Your report will be sent to you immediately<br><br>
				</div>
			</div>
			<br><br>
			<!-- start related articles table  --> 
			<table cellspacing="2" cellpadding="4" border="0" align="center" width="550">
				<tr>
					<td>
					<!-- article box layout -->
					<div style="padding: 3px;  font-size: 11px; color: #000000;">
					<div style="font-size: 13px; color: #7C7C7C;"><strong>{Y1}</strong></div><span style="font-size: 9px; color: #7C7C7C;">{NEW_CONTENT}&nbsp;&nbsp;<a href="articles/{Y0}">read more &raquo;</a><br><br>
					<!-- BEGIN list -->
						<li><a href="articles/{XXX0}" target="_blank" title="{XXX1}">{XXX1}</a>
					<!-- END list -->
					</div>
					</td>
				</tr>
			</table>
		</form>
		</td>
	</tr>
</table>
{FOOTER}