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| <form action="http://forms.sgbd.com/4daction/emailcgi" method="post" name="farm" target="_self" id="farm" onsubmit="return champsok()">
<table width="600" border="0" align="center" cellpadding="6" cellspacing="2" bgcolor="#FFFFFF">
<tr>
<td colspan="2" align="center" bgcolor="#1E9AD8"><div align="center" class="Style7"><font size="1" face="Arial, Helvetica, sans-serif">*Fields to be filled imperatively</font></div></td>
</tr>
<tr>
<td colspan="2" align="center" bgcolor="#1E9AD8"><div align="left" class="Style98"><strong><font size="1" face="Arial, Helvetica, sans-serif">
<label></label>
</font></strong>
<label>
<input type="radio" name="Gender" value="Mrs" />
<span class="Style93"><font face="Arial, Helvetica, sans-serif">Mrs</font></span>
<input type="radio" name="Gender" value="Ms" />
</label>
<span class="Style93"><font face="Arial, Helvetica, sans-serif">Ms</font></span>
<label>
<input type="radio" name="Gender" value="Mr" />
<span class="Style93"><font face="Arial, Helvetica, sans-serif">Mr</font></span> </label>
</div></td>
</tr>
<tr bgcolor="#FF0000">
<td width="215" align="center" bgcolor="#1E9AD8"><div align="left" class="Style97"> <font face="Arial, Helvetica, sans-serif">Family Name*</font></div></td>
<td width="375" bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input name="LastName" type="text" id="LastName" style="width: 100%;" />
</font></div></td>
</tr>
<tr>
<td align="center" bgcolor="#1E9AD8"><div align="left" class="Style97"><font face="Arial, Helvetica, sans-serif">First Name*</font></div></td>
<td bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input name="FirstName" type="text" id="FirstName" style="width: 100%;" />
</font></div></td>
</tr>
<tr>
<td align="center" bgcolor="#1E9AD8"><div align="left" class="Style97"><font face="Arial, Helvetica, sans-serif">Title*</font></div></td>
<td bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input name="Title" type="text" id="Title" style="width: 100%;" />
</font></div></td>
</tr>
<tr>
<td width="215" align="center" bgcolor="#1E9AD8"><div align="left" class="Style94"><strong>Rank* (no abbrevations)</strong><br />
</div></td>
<td width="375" bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input name="Rank" type="text" id="Rank" style="width: 100%;" />
</font></div></td>
</tr>
</table>
<br />
<table width="600" border="0" align="center" cellpadding="6" cellspacing="2" bgcolor="#FFFFFF">
<tr>
<td width="215" align="center" bgcolor="#1E9AD8"><div align="left" class="Style97"><font face="Arial, Helvetica, sans-serif">Institution*</font></div></td>
<td width="375" bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input type="text" name="Institution" style="width: 100%;"/>
</font></div></td>
</tr>
<tr>
<td width="215" height="2" align="center" valign="middle" bgcolor="#1E9AD8"><div align="left" class="Style97"><font face="Arial, Helvetica, sans-serif">Phone*</font></div></td>
<td width="375" bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input type="text" name="Tel" style="width: 100%;" />
</font></div></td>
</tr>
<tr>
<td width="215" align="center" valign="middle" bgcolor="#1E9AD8"><div align="left" class="Style97"><font face="Arial, Helvetica, sans-serif">Mobile Phone*</font></div></td>
<td width="375" bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input type="text" name="Mobile" style="width: 100%;" id="Mobile" />
</font></div></td>
</tr>
<tr>
<td width="215" height="25" align="center" bgcolor="#1E9AD8"><div align="left" class="Style97"><font face="Arial, Helvetica, sans-serif"> E-mail*</font></div></td>
<td width="375" bgcolor="#1E9AD8"><div align="center" class="Style98"><font size="2" face="Arial, Helvetica, sans-serif">
<input type="text" name="Email" style="width: 100%;" />
</font></div></td>
</tr>
<tr bgcolor="#FFFFFF">
<td height="25" colspan="2" align="center" bgcolor="#FFFFFF"> </td>
</tr>
</table>
<br />
<table width="600" align="center" cellpadding="6" cellspacing="2" bgcolor="#FFFFFF">
<tr>
<td width="594" bgcolor="#1E9AD8"><div align="center" class="Style104"><span class="Style93"><font color="#FFFFFF" face="Arial, Helvetica, sans-serif">Message </font></span><font color="#FFFFFF" face="Arial, Helvetica, sans-serif"><em>
<textarea name="Message" cols="80" rows="10" style="width: 100%;"></textarea>
</em></font></div></td>
</tr>
</table>
<p align="center"><font size="2" face="Times New Roman, Times, serif">
<input name="Submit" type="submit" value="Submit" />
<input name="reset" type="reset" id="Clear" value="Clear" />
<input type="hidden" name="vw_destinataire" value="info@cimm-icmm.org" />
<input type="hidden" name="vw_sujet" value="ICMM Contact" />
<input type="hidden" name="vw_pageretour" value="http://www.cimm-icmm.org/page/anglais/SendOKcontactsanTxte.php" />
</font></p>
<p align="center" class="MsoNormal Style77"> </p>
</form> |
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