GO GREEN FORM

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=210 BGCOLOR="#99CC99" TEXT="#080000" bgproperties="fixed" background="0388dfc3.jpg"> <div>                                                   </div> <div> <A HREF="id2.htm" TARGET="_top" TITLE="Weekly Specials"><U>Click to Return </U></A></div> <div> <A HREF="id2.htm" TARGET="_top" TITLE="Weekly Specials"><U>to Weekly Specials</U></A><FONT SIZE="2" COLOR="#006600" FACE="Arial" ><B> </B></FONT></div> </td> <td valign="top" colspan=2 height=82 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0398dfe1esnpes.jpg"> <div> <FONT SIZE="6" COLOR="#990033" FACE="Tempus Sans ITC" >Johnny Paisano's</FONT><B>    </B><B>|</B><FONT SIZE="4" COLOR="#336699" FACE="Tempus Sans ITC" ><B>     </B><A HREF="index.htm" TARGET="_top" TITLE=" Johnny Paisanos"><U><B>home</B></U></A></FONT></div> <bR> <div> </div> </td> </tr><tr> <td valign="top" height=398 colspan=2 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0398dfc3.jpg"> <div> GO GREEN FORM</div> <div> COMPLETE THE FORM BELOW TO HAVE </div> <div> JOHNNY PAISANO'S WEEKLY SPECIALS </div> <div> AND COUPONS SENT DIRECTLY TO YOUR EMAIL!!</div> <bR> <div>    <form enctype="multipart/form-data" method="post" action="http://www.freedback.com/mail.php" accept-charset="UTF-8"> <div> <input type="hidden" name="acctid" id="acctid" value="icb4smwugmud6cz8" /> <input type="hidden" name="formid" id="formid" value="576313" /> <input type="hidden" name="required_vars" id="required_vars" value="email,field-f7fd3924f0ca60a" /> </div> <table cellspacing="5" cellpadding="5" border="0"> <tr> <td valign="top"> <strong>Name:</strong> </td> <td valign="top"> <input type="text" name="name" id="name" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Email Address:</strong> </td> <td valign="top"> <input type="text" name="email" id="email" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Please send me Weekly Specials and Special Offers for...</strong> </td> <td valign="top"> <input type="checkbox" name="field-f7fd3924f0ca60a[]" id="field-f7fd3924f0ca60a_0" value="Johnny Paisano's Springfield" /> Johnny Paisano's Springfield<br/> <input type="checkbox" name="field-f7fd3924f0ca60a[]" id="field-f7fd3924f0ca60a_1" value="Johnny Paisano's Gourmet to Go (Aston)" /> Johnny Paisano's Gourmet to Go (Aston)<br/> </td> </tr> <tr> <td valign="top"> <strong>If you received faxes from Johnny Paisano's, please list your fax number:</strong> </td> <td valign="top"> <input type="text" name="field-d006dd3fec328bc" id="field-d006dd3fec328bc" size="40" value="" /> </td> </tr> <tr> <td colspan="2" align="center"> <input type="submit" value=" Submit Form " /> </td> </tr> </table> </form> <br><center><font face="Arial, Helvetica" size="1"><b> <a href="http://www.freedback.com">form creator</a> </b></font></center>   </div> </td> </tr></table></body>