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| <div align="center">
<form action="http://www.mondomaine.com/autoreponder/subscribe.php" method="post">
<table width="153" border="0" align="center" cellpadding="0" cellspacing="0">
<tr>
<td colspan="3"><img src="images3/optin_01.gif" alt="" width="154" height="111"></td>
</tr>
<td colspan="3">
<img src="images3/optin_02.gif" alt="" width="154" height="26"></td>
</tr>
<tr>
<td colspan="3" background="images3/optin_03.gif"><div align="center"><p align="center">
<input type="text" name="name" size="16" maxlength="50"></div></td>
</tr>
<tr>
<td colspan="3"><img src="images3/optin_04.gif" alt="" width="154" height="20"></td>
</tr>
<tr>
<td colspan="3" background="images3/optin_05.gif"><div align="center"><input type="text" name="email" size="16" maxlength="100"></div></td>
</tr>
<tr>
<td height="34" colspan="3"><input type="image" value="Inscrivez-vous maintenant!" src="images3/optin_06.gif" alt="" width="154" height="34"></td>
</tr>
<tr>
<td height="35" colspan="3" valign="top"><img src="images3/optin_07.gif" alt="" width="154" height="23"></td>
</tr>
</table>
<input type="hidden" name="user_id" value="2">
<input type="hidden" name="redirect" value="">
</form>
</div> |