Open Account & Request Catalog

<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" background="25c785a3.jpg"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>Joseph Falkenstein Inc</B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE="Joseph Falkenstein Inc"><U><B>home</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="About Us"><U>About Us</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="Online Catalog"><U>Online Catalog</U></A>   |   <A HREF="id156.htm" TARGET="_top" TITLE="Latest Fancy Cuts"><U>Latest Fancy Cuts</U></A>   |   <A HREF="id27.htm" TARGET="_top" TITLE="Weekly Gemstones Specials"><U>Weekly Gemstones Specials</U></A>   |   <A HREF="online_store.htm" TARGET="_top" TITLE="Shop Online"><U>Shop Online</U></A>   |   <A HREF="id141.htm" TARGET="_top" TITLE="Pay Your Bills Online Save"><U>Pay Your Bills Online & Save</U></A>   |   <B>Open Account & Request Catalog</B>   |   <A HREF="id19.htm" TARGET="_top" TITLE="Our Location"><U>Our Location</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="News and Events"><U>News and Events</U></A>   |   <A HREF="id31.htm" TARGET="_top" TITLE="Holiday Schedule"><U>Holiday Schedule</U></A>   |   <A HREF="id46.htm" TARGET="_top" TITLE="Recommended Vendor List"><U>Recommended Vendor List</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="FAQ"><U>FAQ</U></A>   |   <A HREF="id116.htm" TARGET="_top" TITLE="Webmail"><U>Webmail</U></A>   |   <A HREF="id134.htm" TARGET="_top" TITLE="Wall Of Shame"><U>Wall Of Shame</U></A>   |   <A HREF="id47.htm" TARGET="_top" TITLE="Contact Us"><U>Contact Us</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="25dd2b03.jpg"> <div> Fill out the following form with your complete details and we will open your account and mail you our catalog. You should receive the catalog within a few days.</div> <a href="http://www.emailmeform.com">Emailmeform</a> <bR> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Open Account & Request Catalog</I></div> <div>  <form method="post" action="http://www.emailmeform.com/fid.php?formid=182819" enctype="multipart/form-data" accept-charset="UTF-8"> <table cellpadding="2" cellspacing="0" border="0" bgcolor="#FFFFFF"> <tr> <td> <font face="Verdana" size="2" color="#000000">If form does not work, please email kenny@falkinc.com </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">Company 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">First 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">Last Name</font></td> <td> <input type="text" name="FieldData2" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Your Title</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">Owners Name</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">Address1</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">Address2</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">City</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">State</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">Zipcode</font></td> <td> <input type="text" name="FieldData9" value="" maxlength="100" size="10"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Phone</font></td> <td> <input type="text" name="FieldData10" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Fax</font></td> <td> <input type="text" name="FieldData11" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Email</font></td> <td> <input type="text" name="FieldData12" value="" maxlength="100" size="30"> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">References</font></td> <td> <textarea name="FieldData13" cols="60" rows="10"></textarea><br> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Join Mailing List</font></td> <td> <input type=checkbox name="FieldData14-0" value="Yes" id="check140"><font face="Verdana" size="2" color="#000000"><label for="check140">Yes</label></font><br><input type=checkbox name="FieldData14-1" value="No" id="check141"><font face="Verdana" size="2" color="#000000"><label for="check141">No</label></font><br> </td> </tr> <tr valign="top"> <td nowrap><font face="Verdana" size="2" color="#000000">Comments</font></td> <td> <textarea name="FieldData15" cols="60" rows="10"></textarea><br> <div style="position: absolute; left: 1800px; top: 20px;"><a href="http://www.captchacreator.com/v-createcaptchacodes.html">captcha code</a></div></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 email" name="Submit"> <input type="reset" class="btn" value=" Clear " name="Clear"></td> </tr> <tr> <td colspan=2 align="center"> <br> </td> </tr> </table> <a href="http://www.emailmeform.com">Emailmeform</a> </form>  </div> <bR> <div>  <a href="http://www.emailmeform.com">web form</a> <a href="http://www.captchacreator.com">captcha</a>  </div> </td> </tr></table></body>