<div class="textwidget"><form action="http://www.vemmabuilder.com/25924236/blog" name="form" method="post">
<table cellspacing="0" bordercolor="#ffffff" align="center" bordercolordark="#ffffff" cellpadding="0
" bordercolorlight="#ffffff" width="317"
class="formfont">
<tr>
<td width="144" class="formfont">名:</td>
<td width="181" class="item"><input maxlength="50" value="" name="surveyFirstName" size="25" type="text" align="left" /></td>
</tr>
<tr>
<td class="formfont">姓:</td>
<td class="item"><input maxlength="50" value="" name="surveyLastName" size="25" type="text" align="left" /></td>
</tr>
<tr>
<td class="formfont">連絡電話:</td>
<td class="item"><input maxlength="30" value="" name="surveyPhone" size="25" type="text" align="left" /></td>
</tr>
<tr>
<td class="formfont">電子信箱:</td>
<td class="item"><input maxlength="50" value="" name="surveyEmail" size="25" type="text" align="left" /></td>
</tr>
<tr>
<td class="formfont">確認電子信箱:</td>
<td class="item"><input maxlength="50" value="" name="surveyConfirmEmail" size="25" type="text" align="left" /></td>
</tr>
<tr>
<td class="formfont">國家:</td>
<td class="item"><select class="formfont" name="surveyCountry"><option value="" />選擇國家<option value="1" />United States<option value="12" />Australia<option value="13" />Austria<option value="36" />Canada<option value="78" />Germany<option value="99" />Ireland<option value="103" />Japan<option value="123" />Malaysia<option value="147" />New Zealand<option value="163" />Philippines<option value="183" />Singapore<option value="184" />Slovenia<option value="197" />Taiwan<option value="213" />United Kingdom</select></td>
</tr>
<tr>
<td width="101" class="formfont">我想每月賺取(美元) :</td>
<td width="233" class="item"><select class="formfont" name="surveyIncomeGoal"><option value="" />Please choose one<option value="0" />Less than $1,000 per month<option value="1" />$1,000 per month<option value="2" />$3,000 per month<option value="3" />$5,000 per month<option value="4" />$10,000 per month or more</select></td>
</tr>
</table>
<div align="center">
<p><font color="#9966ff"><input value="註冊免費準會員" name="surveysubmit" onclick="exit=false" type="submit" /></font></p>
<p class="spacer"> </p>
<table border="" bordercolor="#000000" width="76%" cellspacing="4" align="center">
<br />
<tr>
<td height="60"> <div class="smaller" align="center"><font face="Arial, Helvetica, sans-serif"><font face="Arial Narrow, Arial, Helvetica, Times New Roman">免費註冊這個令人難以置信的系統，註冊後您將鎖定位置，以確保在線收入。每當有另一人在你下面的位置時，我們會向您發送電子郵件。詳細資料註冊後即可瀏覽...</font></font></div></td>
</tr></table></div></form></div>