<!-- Standard inclusions for all personal details screens. -->

<img src=/icons/bullets/purple.gif width=10 height=10>
<b>$$$ Plug-and-Pay $$$</b><br>

We will send you a cheque for US$20.00 for every 
customer that is referred to our site via 
your site, when they purchase PowerWeb. We will use these details when we mail your cheque.

<Input type=hidden name=Product		value="<!--#echo var=Product		-->">
<Input type=hidden name=Platform		value="<!--#echo var=Platform		-->">
<Input type=hidden name=Method		value="<!--#echo var=Method		-->">
<Input type=hidden name=EMail			value="<!--#echo var=EMail			-->">
<Input type=hidden name=Host			value="<!--#echo var=Host			-->">
<Input type=hidden name=IPAddress	value="<!--#echo var=IPAddress	-->">
<Input type=hidden name=ServerIP		value="<!--#echo var=ServerIP		-->">
<Input type=hidden name=ServerPort	value="<!--#echo var=ServerPort	-->">
<Input type=hidden name=Referal		value="<!--#echo var=Referal		-->">
<Input type=hidden name=Referer		value="<!--#echo var=Referer		-->">
<Input type=hidden name=ListKeep		value="<!--#echo var=ListKeep		-->">
<Input type=hidden name=ListRemove	value="<!--#echo var=ListRemove	-->">

<table border=0>
<tr>
	<th><h3>Personal Details</h2>
	<th>______
	<th><h3>Telephone Details</h2>
<tr>
	<td>
	<table border=0>
	<tr>
		<td><b>First Name:</b>
		<td><b>Last Name:</b>
	<tr>
		<td><Input Type=text Name=FirstName Size=12 MaxLength=255>
		<td><Input Type=text Name=LastName Size=22 MaxLength=255>
	</table>

	<td>
	<td>
	<table border=0>
	<tr>
		<td><b>Country Code:</b>
		<td><b>Area Code:</b>
	<tr>
		<td><Input Type=text Name=TelCountry Size=14 MaxLength=255>
		<td><Input Type=text Name=TelArea Size=14 MaxLength=255>
	</table>
<tr>
	<td>
	<b>Company Name:</b><br>
	<Input Type=text Name=Company Size=36 MaxLength=255>
	<td>
	<td>
	<table border=0>
	<tr>
		<td><b>Daytime Telephone:</b>
		<td><b>Night Telephone:</b>
	<tr>
		<td><Input Type=text Name=DayPhone Size=14 MaxLength=255>
		<td><Input Type=text Name=NightPhone Size=14 MaxLength=255>
	</table>
<tr>
	<td>
	<b>Postal Address:</b><br>
	<Input Type=text Name=Addr1 Size=36 MaxLength=255><br>
	<Input Type=text Name=Addr2 Size=36 MaxLength=255>
	<td>
	<td>
	<table border=0>
	<tr>
		<td><b>Fax Number:</b>
		<td><b>GMT Time Zone:</b>
	<tr>
		<td><Input Type=text Name=Fax Size=14 MaxLength=255>
		<td><Input Type=text Name=TimeZone Size=14 MaxLength=255>
	</table>
<tr>
	<td>
	<table border=0>
	<tr>
		<td><b>City:</b>
		<td><b>Zip Code:</b>
	<tr>
		<td><Input Type=text Name=City Size=20 MaxLength=255>
		<td><Input Type=text Name=Zip Size=10 MaxLength=255>
	</table>
	<td>
	<td>
<tr>
	<td>
	<table border=0>
	<tr>
		<td><b>State or Province:</b>
		<td><b>Country:</b>
	<tr>
		<td><Input Type=text Name=State Size=15 MaxLength=255>
		<td><Input Type=text Name=Country Size=15 MaxLength=255>
	</table>
	<td>
	<td>
		
</table>

<p>

