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<form name="survey_2040" id="survey_2040" method="POST" action="http://act.alz.org/site/Survey" target="_top" > <input type="hidden" name="cons_info_component" id="cons_info_component" value="t" style="display: none; visibility: hidden;" /> <table width="280" cellpadding="0" cellspacing="0" border="0" style="background: white; border-width: 3px; border-style: solid; border-color: #ffac00; font-family: Arial, Verdana, sans-serif; font-size: 12px;"> <tr> <td align="right" valign="top" colspan="3" style="padding-right: 5px; padding-top: 15px; padding-bottom: 10px; padding-left:0px"><img src="http://alz.org/images_custom/myspace/ms_alz_logo.gif"></td> </tr> <tr> <td rowspan="14" width="10"></td> <td colspan="2"><p style="color: #e04b0c; font-weight: bold; font-size: 14px; margin-top: 10px; margin-bottom: 10px;">Sign up and be counted as a Champion!</p></td> <td rowspan="14" width="10"></td> </tr> <tr> <td width="100">First name:</td> <td width="180"><input type="text" name="cons_first_name" id="cons_first_name" value="" size="22" maxlength="50" /></td> </tr> <tr> <td colspan="2" height="5"><font size="-1" color="white">.</font></td> </tr> <tr> <td>Last name:</td> <td><input type="text" name="cons_last_name" id="cons_last_name" value="" size="22" maxlength="50" /></td> </tr> <tr> <td colspan="2" height="5"><font size="-1" color="white">.</font></td> </tr> <tr> <td>E-mail:</td> <td><input type="text" name="cons_email" id="cons_email" value="" size="22" maxlength="255" /></td> </tr> <tr> <td colspan="2" height="5"><font size="-1" color="white">.</font></td> </tr> <tr> <td>ZIP:</td> <td><input type="text" name="cons_zip_code" id="cons_zip_code" value="" size="10" maxlength="40" /></td> </tr> <input type="hidden" name="cons_mail_opt_in" id="cons_mail_opt_in" value="t" style="display: none; visibility: hidden;" /> <tr> <td colspan="2" height="5"><font size="-1" color="white">.</font></td> </tr> <tr> <td colspan="2">Check to receive email <input type="checkbox" name="cons_email_opt_in" id="cons_email_opt_in" checked="checked" /></td> </tr> <input type="hidden" id="cons_email_opt_in_requested" name="cons_email_opt_in_requested" value="true" style="display: none; visibility: hidden;" /> <input type="hidden" name="1796_2040_2_2381" id="1796_2040_2_2381_1" value="1101" style="display: none; visibility: hidden;" /> <tr> <td colspan="2" align="right"> <input type="submit" name="ACTION_SUBMIT_SURVEY_RESPONSE" id="ACTION_SUBMIT_SURVEY_RESPONSE" value="Sign up" class="Button" style="margin-right: 25px;" /> </td> </tr> <tr> <td> </td> </tr> <input type="hidden" name="SURVEY_ID" id="SURVEY_ID" value="2040" style="display: none; visibility: hidden;" /> </table> </form>

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