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<form method=”post” action=”https://www.ynotmail.com/clients/form.php?form=1482″ id=”frmSS1482″ onsubmit=”return CheckForm1482(this);”>
<table border=”0″ cellpadding=”2″ class=”myForm”>
<tr>
<td>&nbsp;&nbsp;&nbsp;&nbsp;First Name:</td>
<td><input type=”text” name=”CustomFields[2]” id=”CustomFields_2_1482″ value=”” size=’50’></td>
</tr><tr>
<td>&nbsp;&nbsp;&nbsp;&nbsp;Last Name:</td>
<td><input type=”text” name=”CustomFields[3]” id=”CustomFields_3_1482″ value=”” size=’50’></td>
</tr><tr>
<td>&nbsp;&nbsp;&nbsp;&nbsp;Birth Date:</td>
<td><select name=”CustomFields[7][dd]” id=”CustomFields_7_dd”><option value=”01″>1</option><option value=”02″>2</option><option value=”03″>3</option><option value=”04″>4</option><option value=”05″>5</option><option value=”06″>6</option><option value=”07″>7</option><option value=”08″>8</option><option value=”09″>9</option><option value=”10″>10</option><option value=”11″>11</option><option value=”12″>12</option><option value=”13″>13</option><option value=”14″>14</option><option value=”15″>15</option><option value=”16″>16</option><option value=”17″>17</option><option value=”18″>18</option><option value=”19″>19</option><option value=”20″>20</option><option value=”21″>21</option><option value=”22″>22</option><option value=”23″>23</option><option value=”24″>24</option><option value=”25″>25</option><option value=”26″>26</option><option value=”27″>27</option><option value=”28″>28</option><option value=”29″>29</option><option value=”30″>30</option><option value=”31″>31</option></select><select name=”CustomFields[7][mm]” id=”CustomFields_7_mm”><option value=”01″>Jan</option><option value=”02″>Feb</option><option value=”03″>Mar</option><option value=”04″>Apr</option><option value=”05″>May</option><option value=”06″>Jun</option><option value=”07″>Jul</option><option value=”08″>Aug</option><option value=”09″>Sep</option><option value=”10″>Oct</option><option value=”11″>Nov</option><option value=”12″>Dec</option></select><select name=”CustomFields[7][yy]” id=”CustomFields_7_yy”><option value=”1910″>1910</option><option value=”1911″>1911</option><option value=”1912″>1912</option><option value=”1913″>1913</option><option value=”1914″>1914</option><option value=”1915″>1915</option><option value=”1916″>1916</option><option value=”1917″>1917</option><option value=”1918″>1918</option><option value=”1919″>1919</option><option value=”1920″>1920</option><option value=”1921″>1921</option><option value=”1922″>1922</option><option value=”1923″>1923</option><option value=”1924″>1924</option><option value=”1925″>1925</option><option value=”1926″>1926</option><option value=”1927″>1927</option><option value=”1928″>1928</option><option value=”1929″>1929</option><option value=”1930″>1930</option><option value=”1931″>1931</option><option value=”1932″>1932</option><option value=”1933″>1933</option><option value=”1934″>1934</option><option value=”1935″>1935</option><option value=”1936″>1936</option><option value=”1937″>1937</option><option value=”1938″>1938</option><option value=”1939″>1939</option><option value=”1940″>1940</option><option value=”1941″>1941</option><option value=”1942″>1942</option><option value=”1943″>1943</option><option value=”1944″>1944</option><option value=”1945″>1945</option><option value=”1946″>1946</option><option value=”1947″>1947</option><option value=”1948″>1948</option><option value=”1949″>1949</option><option value=”1950″>1950</option><option value=”1951″>1951</option><option value=”1952″>1952</option><option value=”1953″>1953</option><option value=”1954″>1954</option><option value=”1955″>1955</option><option value=”1956″>1956</option><option value=”1957″>1957</option><option value=”1958″>1958</option><option value=”1959″>1959</option><option value=”1960″>1960</option><option value=”1961″>1961</option><option value=”1962″>1962</option><option value=”1963″>1963</option><option value=”1964″>1964</option><option value=”1965″>1965</option><option value=”1966″>1966</option><option value=”1967″>1967</option><option value=”1968″>1968</option><option value=”1969″>1969</option><option value=”1970″>1970</option><option value=”1971″>1971</option><option value=”1972″>1972</option><option value=”1973″>1973</option><option value=”1974″>1974</option><option value=”1975″>1975</option><option value=”1976″>1976</option><option value=”1977″>1977</option><option value=”1978″>1978</option><option value=”1979″>1979</option><option value=”1980″>1980</option><option value=”1981″>1981</option><option value=”1982″>1982</option><option value=”1983″>1983</option><option value=”1984″>1984</option><option value=”1985″>1985</option><option value=”1986″>1986</option><option value=”1987″>1987</option><option value=”1988″>1988</option><option value=”1989″>1989</option><option value=”1990″>1990</option><option value=”1991″>1991</option><option value=”1992″>1992</option><option value=”1993″>1993</option><option value=”1994″>1994</option><option value=”1995″>1995</option><option value=”1996″>1996</option><option value=”1997″>1997</option><option value=”1998″>1998</option><option value=”1999″>1999</option><option value=”2000″>2000</option><option value=”2001″>2001</option><option value=”2002″>2002</option><option value=”2003″>2003</option><option value=”2004″>2004</option><option value=”2005″>2005</option><option value=”2006″>2006</option><option value=”2007″>2007</option><option value=”2008″>2008</option><option value=”2009″>2009</option><option value=”2010″>2010</option></select></td>
</tr><tr>
<td><span class=”required”>*</span>&nbsp;
Your Email Address:</td>
<td><input type=”text” name=”email” value=”” /></td>
</tr><tr>
<td>&nbsp;&nbsp;&nbsp;&nbsp;State:</td>
<td><input type=”text” name=”CustomFields[9]” id=”CustomFields_9_1482″ value=”” size=’50’></td>
</tr><tr>
<td>&nbsp;&nbsp;&nbsp;&nbsp;Country:</td>
<td><select name=”CustomFields[11]” id=”CustomFields_11_1482″><option value=””></option><option value=”AFG”>Afghanistan</option><option value=”ALB”>Albania</option><option value=”DZA”>Algeria</option><option value=”ASM”>American Samoa</option><option value=”AND”>Andorra</option><option value=”AGO”>Angola</option><option value=”AIA”>Anguilla</option><option value=”ATG”>Antigua and Barbuda</option><option value=”ARG”>Argentina</option><option value=”ARM”>Armenia</option><option value=”ABW”>Aruba</option><option value=”AUS”>Australia</option><option value=”AUT”>Austria</option><option value=”AZE”>Azerbaijan</option><option value=”BHS”>Bahamas</option><option value=”BHR”>Bahrain</option><option value=”BGD”>Bangladesh</option><option value=”BRB”>Barbados</option><option value=”BLR”>Belarus</option><option value=”BEL”>Belgium</option><option value=”BLZ”>Belize</option><option value=”BEN”>Benin</option><option value=”BMU”>Bermuda</option><option value=”BTN”>Bhutan</option><option value=”BOL”>Bolivia</option><option value=”BIH”>Bosnia and Herzegovina</option><option value=”BWA”>Botswana</option><option value=”NUL”>Timor-Leste</option><option value=”BRA”>Brazil</option><option value=”BRN”>Brunei Darussalam</option><option value=”BGR”>Bulgaria</option><option value=”BFA”>Burkina Faso</option><option value=”BDI”>Burundi</option><option value=”KHM”>Cambodia</option><option value=”CMR”>Cameroon</option><option value=”CAN”>Canada</option><option value=”CPV”>Cape Verde</option><option value=”CYM”>Cayman Islands</option><option value=”CAF”>Central African Republic</option><option value=”TCD”>Chad</option><option value=”CHL”>Chile</option><option value=”CHN”>China</option><option value=”COL”>Colombia</option><option value=”COM”>Comoros</option><option value=”COG”>Congo</option><option value=”COD”>Congo, the Democratic Republic of the</option><option value=”COK”>Cook Islands</option><option value=”CRI”>Costa Rica</option><option value=”HRV”>Croatia</option><option value=”CUB”>Cuba</option><option value=”CYP”>Cyprus</option><option value=”CZE”>Czech Republic</option><option value=”DNK”>Denmark</option><option value=”DJI”>Djibouti</option><option value=”DMA”>Dominica</option><option value=”DOM”>Dominican Republic</option><option value=”ECU”>Ecuador</option><option value=”EGY”>Egypt</option><option value=”SLV”>El Salvador</option><option value=”GNQ”>Equatorial Guinea</option><option value=”ERI”>Eritrea</option><option value=”EST”>Estonia</option><option value=”ETH”>Ethiopia</option><option value=”FLK”>Falkland Islands (Malvinas)</option><option value=”FRO”>Faroe Islands</option><option value=”FJI”>Fiji</option><option value=”FIN”>Finland</option><option value=”FRA”>France</option><option value=”GUF”>French Guiana</option><option value=”PYF”>French Polynesia</option><option value=”GAB”>Gabon</option><option value=”GMB”>Gambia</option><option value=”GEO”>Georgia</option><option value=”DEU”>Germany</option><option value=”GHA”>Ghana</option><option value=”GIB”>Gibraltar</option><option value=”GRC”>Greece</option><option value=”GRL”>Greenland</option><option value=”GRD”>Grenada</option><option value=”GLP”>Guadeloupe</option><option value=”GUM”>Guam</option><option value=”GTM”>Guatemala</option><option value=”GIN”>Guinea</option><option value=”GNB”>Guinea-Bissau</option><option value=”GUY”>Guyana</option><option value=”HTI”>Haiti</option><option value=”VAT”>Holy See (Vatican City State)</option><option value=”HND”>Honduras</option><option value=”HKG”>Hong Kong</option><option value=”HUN”>Hungary</option><option value=”ISL”>Iceland</option><option value=”IND”>India</option><option value=”IDN”>Indonesia</option><option value=”IRN”>Iran, Islamic Republic of</option><option value=”IRQ”>Iraq</option><option value=”IRL”>Ireland</option><option value=”ISR”>Israel</option><option value=”ITA”>Italy</option><option value=”JAM”>Jamaica</option><option value=”JPN”>Japan</option><option value=”JOR”>Jordan</option><option value=”KAZ”>Kazakhstan</option><option value=”KEN”>Kenya</option><option value=”KIR”>Kiribati</option><option value=”KOR”>Korea, Republic of</option><option value=”KWT”>Kuwait</option><option value=”KGZ”>Kyrgyzstan</option><option value=”LVA”>Latvia</option><option value=”LBN”>Lebanon</option><option value=”LSO”>Lesotho</option><option value=”LBR”>Liberia</option><option value=”LBY”>Libyan Arab Jamahiriya</option><option value=”LIE”>Liechtenstein</option><option value=”LTU”>Lithuania</option><option value=”LUX”>Luxembourg</option><option value=”MAC”>Macao</option><option value=”MKD”>Macedonia, the Former Yugoslav Republic of</option><option value=”MDG”>Madagascar</option><option value=”MWI”>Malawi</option><option value=”MYS”>Malaysia</option><option value=”MDV”>Maldives</option><option value=”MLI”>Mali</option><option value=”MLT”>Malta</option><option value=”MHL”>Marshall Islands</option><option value=”MTQ”>Martinique</option><option value=”MRT”>Mauritania</option><option value=”MUS”>Mauritius</option><option value=”MEX”>Mexico</option><option value=”FSM”>Micronesia, Federated States of</option><option value=”MDA”>Moldova, Republic of</option><option value=”MCO”>Monaco</option><option value=”MNG”>Mongolia</option><option value=”MSR”>Montserrat</option><option value=”MAR”>Morocco</option><option value=”MOZ”>Mozambique</option><option value=”MMR”>Myanmar</option><option value=”NAM”>Namibia</option><option value=”NRU”>Nauru</option><option value=”NPL”>Nepal</option><option value=”NLD”>Netherlands</option><option value=”ANT”>Netherlands Antilles</option><option value=”NCL”>New Caledonia</option><option value=”NZL”>New Zealand</option><option value=”NIC”>Nicaragua</option><option value=”NER”>Niger</option><option value=”NGA”>Nigeria</option><option value=”NIU”>Niue</option><option value=”NFK”>Norfolk Island</option><option value=”MNP”>Northern Mariana Islands</option><option value=”NOR”>Norway</option><option value=”OMN”>Oman</option><option value=”PAK”>Pakistan</option><option value=”PLW”>Palau</option><option value=”PAN”>Panama</option><option value=”PNG”>Papua New Guinea</option><option value=”PRY”>Paraguay</option><option value=”PER”>Peru</option><option value=”PHL”>Philippines</option><option value=”PCN”>Pitcairn</option><option value=”POL”>Poland</option><option value=”PRT”>Portugal</option><option value=”PRI”>Puerto Rico</option><option value=”QAT”>Qatar</option><option value=”REU”>Reunion</option><option value=”ROM”>Romania</option><option value=”RUS”>Russian Federation</option><option value=”RWA”>Rwanda</option><option value=”SHN”>Saint Helena</option><option value=”KNA”>Saint Kitts and Nevis</option><option value=”LCA”>Saint Lucia</option><option value=”SPM”>Saint Pierre and Miquelon</option><option value=”VCT”>Saint Vincent and the Grenadines</option><option value=”WSM”>Samoa</option><option value=”SMR”>San Marino</option><option value=”STP”>Sao Tome and Principe</option><option value=”SAU”>Saudi Arabia</option><option value=”SEN”>Senegal</option><option value=”SRB”>Serbia</option><option value=”SYC”>Seychelles</option><option value=”SLE”>Sierra Leone</option><option value=”SGP”>Singapore</option><option value=”SVK”>Slovakia</option><option value=”SVN”>Slovenia</option><option value=”SLB”>Solomon Islands</option><option value=”SOM”>Somalia</option><option value=”ZAF”>South Africa</option><option value=”ESP”>Spain</option><option value=”LKA”>Sri Lanka</option><option value=”SDN”>Sudan</option><option value=”SUR”>Suriname</option><option value=”SJM”>Svalbard and Jan Mayen</option><option value=”SWZ”>Swaziland</option><option value=”SWE”>Sweden</option><option value=”CHE”>Switzerland</option><option value=”SYR”>Syrian Arab Republic</option><option value=”TWN”>Taiwan, Province of China</option><option value=”TJK”>Tajikistan</option><option value=”TZA”>Tanzania, United Republic of</option><option value=”THA”>Thailand</option><option value=”TGO”>Togo</option><option value=”TKL”>Tokelau</option><option value=”TON”>Tonga</option><option value=”TTO”>Trinidad and Tobago</option><option value=”TUN”>Tunisia</option><option value=”TUR”>Turkey</option><option value=”TKM”>Turkmenistan</option><option value=”TCA”>Turks and Caicos Islands</option><option value=”TUV”>Tuvalu</option><option value=”UGA”>Uganda</option><option value=”UKR”>Ukraine</option><option value=”ARE”>United Arab Emirates</option><option value=”GBR”>United Kingdom</option><option value=”USA”>United States</option><option value=”URY”>Uruguay</option><option value=”UZB”>Uzbekistan</option><option value=”VUT”>Vanuatu</option><option value=”VEN”>Venezuela</option><option value=”VNM”>Viet Nam</option><option value=”VGB”>Virgin Islands, British</option><option value=”VIR”>Virgin Islands, U.s.</option><option value=”WLF”>Wallis and Futuna</option><option value=”ESH”>Western Sahara</option><option value=”YEM”>Yemen</option><option value=”ZMB”>Zambia</option><option value=”ZWE”>Zimbabwe</option></select></td>
</tr><tr>
<td><span class=”required”>*</span>&nbsp;
Preferred Format:</td>
<td><select name=”format”><option value=”h”>HTML</option><option value=”t”>Text</option></select></td>
</tr><tr>
<td><span class=”required”>*</span>&nbsp;
Enter the security code shown:</td>
<td><script type=”text/javascript”>
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return Application.Page.ClientCAPTCHA.sessionIDString;
},
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tempURL += ‘&ss=’ + Application.Page.ClientCAPTCHA.getSID();
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}
return Application.Page.ClientCAPTCHA.captchaURL;
}
}
}

var temp = Application.Page.ClientCAPTCHA.getURL();
for (var i = 0, j = temp.length; i < j; i++) document.write(‘<img src=”‘ + temp[i] + ‘” alt=”img’ + i + ‘” />’);
// ]]>
</script>
<br/><input type=”text” name=”captcha” value=”” /></td>
</tr>
<tr>
<td></td>
<td>
<input type=”submit” value=”Subscribe” />
<br/>
</td>
</tr>
</table>
</form>

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