Ethnic Barbershop Registration Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=143 BGCOLOR="#000000" TEXT="#F7F7FF"> <div> <A HREF="index.htm" TARGET="_top" TITLE="The Ethnic Barbershop Directory"><U><B><IMG SRC="341f4410.jpg" border=0 width="500" height="65" ALT="Back to the Styles" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <bR> <div> <I><B>PROMOTE YOUR BARBERSHOP REACH </B></I><FONT SIZE="4" COLOR="#FF6633" FACE="Arial Black" ><I><B>MORE</B></I></FONT><I><B> PEOPLE THAN THE </B></I><FONT SIZE="4" COLOR="#FFCC33" FACE="Arial Black" ><I><B>YELLOW PAGES</B></I></FONT></div> <div> <I><B>FOR LESS THAN A </B></I><FONT SIZE="4" COLOR="#EEEEEE" FACE="Arial Black" ><I><B>NEWSPAPER</B></I></FONT><I><B> AD</B></I></div> </td> </tr><tr> <td valign="top" height=337 BGCOLOR="#000000" TEXT="#F7F7FF"> <bR> <div> <A HREF="mailto:blackbarbershops@earthlink.net" TARGET="_top" TITLE="mailto:blackbarbershops@earthlink.net"><U><IMG SRC="3aad43c0.jpg" border=0 width="468" height="60" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <FONT SIZE="4" COLOR="#FFCC33" FACE="Arial Black" ><I><B>THANK YOU!</B></I></FONT><FONT SIZE="4" COLOR="#FFCC33" FACE="Arial Black" ><I><B> </B></I></FONT><I><B> </B></I><I>FOR BECOMING A MEMBER</I></div> <div> <I><B>REACH MORE PEOPLE THAN THE  </B></I><FONT SIZE="2" COLOR="#FFFF00" FACE="Arial" ><I><B>YELLOW PAGES</B></I></FONT></div> <div> <I><B>FOR LESS THAN A </B></I><FONT SIZE="2" COLOR="#FFFFFF" FACE="Arial" ><I><B>NEWSPAPER</B></I></FONT><I><B> AD</B></I></div> <bR> <div> <TABLE BORDER="1" CELLPADDING="1" CELLSPACING="0" WIDTH="534" BORDERCOLORLIGHT="#000000" BORDERCOLORDARK="#000000" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#993300 > <tR> <tD VALIGN=TOP BGCOLOR=#CC9922 HEIGHT= 40 WIDTH="528"><div> <B>Your Barbershop Name Here</B></div> <div> 5425 W.    55th St.   <I>Harlem</I>     212.555.1212</div> </tD> </tR> </TABLE></div> <bR> <div> <B>(</B><I><B>BARBERSHOPS ONLY ....PLEASE COMPLETE THE FOLLOWING FORM</B></I><B> )</B></div> <div> <B> <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="Barbershop Name,FirstName,LastName,Address1,Address2,City,State,Zip,Phone,Email,website,MailingList"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for becoming a member of the Ehtnic Barbershop Directory"><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A Barbershop listing form was submitted"><input type="hidden" name="tlx_EmailTo" value="barbershops@black-barbershops.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Company:<br> <input type="text" name="Barbershop Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Owner Name(first):<br> <input type="text" name="FirstName" size="30" maxlength="30"></td> </tr> <tr> <td align="left">Owner Name(last):<br> <input type="text" name="LastName" size="30" maxlength="30"></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">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">website,facebook or myspace:<br> <input type="text" name="website" size="30" maxlength="100"></td> </tr> <tr> <td> <input type="checkbox" name="MailingList" value="yes"> Add me to your mailing list</td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </B></div> <div>  <A NAME="shop_form_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <I><B>THANK YOU! </B></I><FONT SIZE="4" COLOR="#FF6633" FACE="Arial" ><I><B> FOR BECOMING A MEMBER</B></I></FONT></div> <div> <B>Ethnic Media & Promotion</B>  <A HREF="mailto:info@black-barbershops.com" TARGET="_top" TITLE="mailto:info@black-barbershops.com"><U>PO Box 962223 Riverdale,Ga 30276</U></A></div> <div> Copyright ©2001-2009  Ethnic Media & Promotion All Rights Reserved.</div> </td> </tr></table></body>