Registration

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="057285a1erlcgo.png"> <div> <B>VP-21 & VPB-111 Veterans Association</B></div> <div> <A HREF="index.htm" TARGET="_top" TITLE=" VP21 VPB111 Veterans Association Member"><U><B>Member Index</B></U></A></div> <div> <A HREF="index.htm" TARGET="_top" TITLE=" VP21 VPB111 Veterans Association Member"><U><B>BACK</B></U></A></div> </td> </tr><tr> <td valign="top" width=150 BGCOLOR="#FFCC66" TEXT="#080000" background="056d4c00dkelyh.png"> <div> <A HREF="http://vp-21.org" TARGET="_top" TITLE="http://vp-21.org"><U><U>HOME</U></U></A></div> <div> <A HREF="http://vp-21.org/biographies" TARGET="_top" TITLE="http://vp-21.org/biographies"><U><U>BIOGRAPHIES</U></U></A></div> <div> <A HREF="http://vp-21.org/history" TARGET="_top" TITLE="http://vp-21.org/history"><U><U>HISTORY</U></U></A></div> <div> <A HREF="http://www.vp-21.org/Rosters_VP21" TARGET="_top" TITLE="http://www.vp-21.org/Rosters_VP21"><U><U>VP-21 Roster</U></U></A></div> <div> <A HREF="http://www.vp-21.org/Rosters_VPB111" TARGET="_top" TITLE="http://www.vp-21.org/Rosters_VPB111"><U><U>VPB-111 Roster</U></U></A></div> <div> <A HREF="http://www.vp-21.org/Rosters_Deceased" TARGET="_top" TITLE="http://www.vp-21.org/Rosters_Deceased"><U><U>Deceased Roster</U></U></A></div> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B>Fill out the form below and we will add you and your info to our rosters:</B></div> <bR> <DIV ALIGN="LEFT"></DIV> <div>  <form method="post" action="http://www.emailmeform.com/fid.php?formid=59856" enctype="multipart/form-data"> <INPUT TYPE=hidden NAME=FCode VALUE="3uxqheqt"> <table cellpadding="2" cellspacing="0" border="0" bgcolor="#FFFFFF"> <tr> <td> <font face="Verdana" size="2" color="#000000">Please fill in the form and press SEND. The information you provide here is for the sole use of the VP-21/ VPB-111 Veterans Association and will NOT be shared with or disclosed to any other entity.</font> <div style="" id="mainmsg"> </div> </td> </tr> </table> <br> <table cellpadding="2" cellspacing="0" border="0" bgcolor="#FFFFFF"> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">First Name</font></td> <td> <input type="text" name="FieldData0" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Last Name</font></td> <td> <input type="text" name="FieldData1" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Address</font></td> <td> <input type="text" name="FieldData2" value="" maxlength="100" size="30"><div style="position:absolute; top:343px; right:1582px;"><b>Tip: How to create free web forms</b><br>Ever needed to create web forms for your website but had trouble in the process? We recommend Emailmeform, a service to create <a href="http://www.emailmeform.com">web forms</a> easy in a few steps. No need to learn HTML or PHP!</div> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">City</font></td> <td> <input type="text" name="FieldData3" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">State and ZIP code (+4 if known)</font></td> <td> <input type="text" name="FieldData4" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Email address</font></td> <td> <input type="text" name="FieldData5" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Telephone Number</font></td> <td> <input type="text" name="FieldData6" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">What years did you serve in the squadron? (ex: 1958 to 1961)</font></td> <td> <input type="text" name="FieldData7" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Rank/ Rate while in the squadron</font></td> <td> <input type="text" name="FieldData8" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Add me to mail list?</font></td> <td> <input type=checkbox name="FieldData9-0" value="Yes" id="check90"><font face="Verdana" size="2" color="#000000"><label for="check90">Yes</label></font><br><input type=checkbox name="FieldData9-1" value="No" id="check91"><font face="Verdana" size="2" color="#000000"><label for="check91">No</label></font><br> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Comments</font></td> <td> <textarea name="FieldData10" cols="30" rows="10"></textarea><br> </td> </tr> <tr> <td colspan="2"> <table cellpadding=5 cellspacing=0 bgcolor="#E4F8E4" width="100%"> <tr bgcolor="#AAD6AA"> <td colspan="2"><font color="#FFFFFF" face="Verdana" size="2"><b>Image Verification</b></font></td> </tr> <tr> <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> ] </td> </tr> </table> </td> </tr> <tr> <td> </td> <td align="right"> <input type="text" name="hida2" value="" maxlength="100" size="3" style="display : none;"> <input type="submit" class="btn" value="SEND" name="Submit"> <input type="reset" class="btn" value=" Clear info " name="Clear"></td> </tr> <tr> <td colspan=2 align="center"> <br> </td> </tr> </table> </form>  </div> </td> </tr></table></body>