Tea Tasting Information Request Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=300 BGCOLOR="#DDDDDD" TEXT="#080000"> <div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="267" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 193 ><NOBR><div> <IMG SRC="78e00bb0.jpg" border=0 width="256" height="187" ALT="Thumbnail photo-etching of a night view of North Lake Harbour, PEI, Canada. 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You will receive a response shortly."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A request form was submitted"><input type="hidden" name="tlx_EmailTo" value="teatastings@east-east.ca"> <table cellpadding="5" cellspacing="1" border="0" align="center"> <tr> <td align="left">First Name: <br> <input type="text" name="firstName" size="30" maxlength="200"> </td> </tr> <tr> <td align="left">Last Name: <br> <input type="text" name="lastName" size="30" maxlength="100"> </td> </tr> <tr> <td align="left">Email: <br> <input type="text" name="email" size="30" maxlength="100"> </td> </tr> <tr> <td align="left">Company: <br> <input type="text" name="company" size="30" maxlength="100"> </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">Fax Number: <br> <input type="text" name="fax" size="14" maxlength="14"> </td> </tr> <tr> <td> <input type="checkbox" name="mailingList" value="yes"> Add me to your mailing list</td> </tr> <tr> <td align="left">Comments: <br> <textarea name="comments" rows="5" cols="30"></textarea> </td> </tr> <tr> <td align="right"> <input type="reset"> <input type="submit" value="Send" name="tlx_send"> </td> </tr> </table> </form>  </div> </tD> </tR> </TABLE></div> <bR> </td> </tr></table></body>