<HTML> <TITLE>Enrollment Form...</TITLE> <HEAD> <META http-equiv=Content-Type content="text/html; charset=unicode"> <META content="Microsoft FrontPage 5.0" name=GENERATOR> <script type="text/javascript"> var _gaq = _gaq || []; _gaq.push(['_setAccount', 'UA-25773852-1']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); </script> </HEAD> <BODY style="font-family: Verdana; font-size: 10px"> <FORM action="SubmitEnrollment.asp" method=post> <table border="2" cellpadding="0" cellspacing="0" style="BORDER-COLLAPSE: collapse; font-size:8pt; font-family:Verdana" bordercolor="#111111" width="100%" bordercolorlight="#6D775E" bordercolordark="#6D775E"> <tr> <td width="100%" bgcolor="#6d775e"><b> <font face="Verdana" size="2" color="#FFFFFF">Enrollment Form</font></b></td> </tr> <tr> <td width="100%">&nbsp;<table border="0" cellpadding="3" style="border-collapse: collapse" bordercolor="#111111" width="100%" height="482"> <tr> <td width="24%" bgcolor="#001B51" height="19"><b> <font color="#FFFFFF" size="1">Personal Information</font></b></td> <td width="76%" bgcolor="#001B51" height="19">&nbsp;</td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="18"><font size="1">First Name:</font></td> <td width="76%" bgcolor="#ABB39F" height="18"> <input type="text" name="FirstName" size="73"></td> </tr> <tr> <td width="24%" height="19"><font size="1">Middle Name:</font></td> <td width="76%" height="19"> <input type="text" name="MiddleName" size="73"></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="19"><font size="1">Last Name:</font></td> <td width="76%" bgcolor="#ABB39F" height="19"> <input type="text" name="LastName" size="73"></td> </tr> <tr> <td width="24%" height="19"><font size="1">Sex:</font></td> <td width="76%" height="19"><select size="1" name="Sex"> <option>Male</option> <option>Female</option> </select></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="43"><font size="1">Address:</font></td> <td width="76%" bgcolor="#ABB39F" height="43"> <textarea rows="4" name="Address" cols="44"></textarea></td> </tr> <tr> <td width="24%" height="19"><font size="1">Country:</font></td> <td width="76%" height="19"><input type="text" name="Country" size="73"></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="19"><font size="1">Email ID:</font></td> <td width="76%" bgcolor="#ABB39F" height="19"> <input type="text" name="EmailID" size="73"></td> </tr> <tr> <td width="24%" height="19"><font size="1">Phone No.:</font></td> <td width="76%" height="19"> <input type="text" name="PhoneNumber" size="73"></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="19"><font size="1">Education Background:</font></td> <td width="76%" bgcolor="#ABB39F" height="19"> <textarea rows="4" name="Education" cols="64"></textarea></td> </tr> <tr> <td width="24%" height="19"><font size="1">Work Experience: (If any)</font></td> <td width="76%" height="19"><textarea rows="4" name="WorkEx" cols="64"></textarea></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="19">&nbsp;</td> <td width="76%" bgcolor="#ABB39F" height="19">&nbsp;</td> </tr> <tr> <td width="24%" bgcolor="#001B51" height="19"><b> <font color="#FFFFFF" size="1">Course Information</font></b></td> <td width="76%" bgcolor="#001B51" height="19">&nbsp;</td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="18"><font size="1">Enroll in Course:</font></td> <td width="76%" bgcolor="#ABB39F" height="18"> <select size="1" name="EnrollCourse"> <option>Champion</option> <option>Yellow Belt</option> <option>Green Belt</option> <option>Black Belt</option> </select></td> </tr> <tr> <td width="24%" height="19"><font size="1">Proposed Start Date:</font></td> <td width="76%" height="19"> <input type="text" name="ProposedStartDate" size="73"></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="18"><font size="1">Special Requirements/Comments:</font></td> <td width="76%" bgcolor="#ABB39F" height="18"> <textarea rows="4" name="Comments" cols="44"></textarea></td> </tr> <tr> <td width="24%" height="19">&nbsp;</td> <td width="76%" height="19">&nbsp;</td> </tr> <tr> <td width="24%" bgcolor="#001B51" height="19"> <font size="1" color="#FFFFFF"><b>Payment Details</b></font></td> <td width="76%" bgcolor="#001B51" height="19">&nbsp;</td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="18"><font size="1">Payment Amount:</font></td> <td width="76%" bgcolor="#ABB39F" height="18"> <input type="text" name="Amount" size="73"></td> </tr> <tr> <td width="24%" height="19"><font size="1">Check/Draft No.:</font></td> <td width="76%" height="19"> <input type="text" name="CheckNumber" size="73"></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="18"><font size="1">Issuing Bank:</font></td> <td width="76%" bgcolor="#ABB39F" height="18"> <input type="text" name="IssuingBank" size="73"></td> </tr> <tr> <td width="24%" height="19"><font size="1">Date of Issue:</font></td> <td width="76%" height="19"><input type="text" name="IssueDate" size="73"></td> </tr> <tr> <td width="24%" bgcolor="#ABB39F" height="18">&nbsp;</td> <td width="76%" bgcolor="#ABB39F" height="18">&nbsp;</td> </tr> <tr> <td width="24%" height="19">&nbsp;</td> <td width="76%" height="19">&nbsp;</td> </tr> <tr> <td width="100%" height="19" colspan="2"> <p align="center"> <input type="submit" value="Submit" name="B1" style="font-family: v">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="reset" value="Reset" name="B2"></td> </tr> </table> <p></td> </tr> <tr> <td width="100%" > <p align="center"><b> <font face="Verdana" size="1"> GA 2006, All rights reserved. </font></b></td> </tr> </table> </FORM> </BODY></HTML>