Application Form </head> <body> <script type="text/javascript"> __compete_code = '667f89f26d96c30e99728fe6a608804d'; (function () { var s = document.createElement('script'), d = document.getElementsByTagName('head')[0] || document.getElementsByTagName('body')[0], t = 'https:' == document.location.protocol ? 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if (start == -1) return false; start += q_param.length; var end = full.indexOf('&', start); if (end == -1) end = full.length; return unescape(full.substring(start, end)).split(" ").join("+"); } var cm_role = "live"; var cm_host = "tripod.lycos.com"; var cm_taxid = "/memberembedded"; var tripod_member_name = "ndgmdumalaog-rizal"; var tripod_member_page = "ndgmdumalaog-rizal/index.html"; var tripod_ratings_hash = "1338661453:c722107ccb2bd022918d99f79066104e"; var lycos_ad_category = null; var lycos_ad_remote_addr = "38.107.179.210"; var lycos_ad_www_server = "www.tripod.lycos.com"; var lycos_ad_track_small = "http://members.tripod.com/adm/img/common/ot_smallframe.gif?rand=379875"; var lycos_ad_track_served = "http://members.tripod.com/adm/img/common/ot_adserved.gif?rand=379875"; var lycos_search_query = getQuery(); </script> <script type="text/javascript" src="http://scripts.lycos.com/catman/init.js"></script> <script type="text/javascript"> var lycos_ad = Array(); var lycos_onload_timer; function lycos_check_size() { var window_width = 0, window_height = 0; if (typeof(window.innerWidth) == 'number' ) { window_width = window.innerWidth; window_height = window.innerHeight; } else if (document.documentElement && (document.documentElement.clientWidth || document.documentElement.clientHeight)) { window_width = document.documentElement.clientWidth; window_height = document.documentElement.clientHeight; } else if (document.body && (document.body.clientWidth || document.body.clientHeight)) { window_width = document.body.clientWidth; window_height = document.body.clientHeight; } var lycos_track_img = document.createElement('img'); if( top == self ) { return 1; } else { if ((window_width < 300) || (window_height < 300)) { lycos_track_img.src=this.lycos_ad_track_small+"&w="+window_width+"&h="+window_height; return 0; } else { lycos_track_img.src=this.lycos_ad_track_served+"&w="+window_width+"&h="+window_height; return 1; } } } function lycos_insert_ads() { var lycos_ad_mgr = new AdManager(); if (this.lycos_search_query) { lycos_ad_mgr.setForcedParam("keyword", this.lycos_search_query); } else if (this.lycos_ad_category && this.lycos_ad_category.find_what) { lycos_ad_mgr.setForcedParam("keyword", this.lycos_ad_category.find_what); } if (this.lycos_ad_category && this.lycos_ad_category.dmoz) { lycos_ad_mgr.setForcedParam("page", this.lycos_ad_category.dmoz); } else { lycos_ad_mgr.setForcedParam("page", "member"); } var lycos_prod_set = lycos_ad_mgr.chooseProductSet(); var slots = ["leaderboard", "leaderboard2"]; for (var slot in slots) { if (lycos_ad_mgr.isSlotAvailable(slots[slot])) { lycos_ad[slots[slot]] = lycos_ad_mgr.getSlot(slots[slot]); } } lycos_ad_mgr.renderFooter(); } function generateHref(atag, template){ atag.href=template.replace('_MYURL_', window.location.href.replace('http://', '')).replace('_MYTITLE_', 'Check%20out%20this%20Tripod%20Member%20site!'); } if (lycos_check_size()) { lycos_insert_ads(); } window.onload = function() { var f = document.getElementById("FooterAd"); var b = document.getElementsByTagName("body")[0]; b.removeChild(f); b.appendChild(f); f.style.display = "block"; } </script> <style> #body .adCenterClass{margin:0 auto} </style> <div id="tb_container" style="background:#DFDCCF; border-bottom:1px solid #393939; position:relative; z-index:999999999!important"> <div id="tb_ad" class="adCenterClass" style="display:block!important; overflow:hidden; width:916px;"> <a href="http://adtrack.ministerial5.com/clicknew/?a=637394" title="build your own website at Tripod.com" style="float:left; width:186px; border:0"> <img src="http://ly.lygo.com/ly/tpSite/images/freeAd2.jpg" alt="Make your own free website on Tripod.com" style="border:0; display:block" /> </a> <div id="ad_container" style="display:block!important; float:left; width:728px "> <script type="text/javascript">document.write(lycos_ad['leaderboard']);</script> </div> </div> </div> <div id="FooterAd" style="background:#DFDCCF; border-top:1px solid #393939; clear:both; display:none; width:100%!important; position:relative; z-index:999999!important; height:90px!important"> <div class="adCenterClass" style="display:block!important; overflow:hidden; width:916px;"> <a href="http://adtrack.ministerial5.com/clicknew/?a=637394" title="build your own website at Tripod.com" style="float:left; display:block; width:186px; border:0"> <img src="http://ly.lygo.com/ly/tpSite/images/freeAd2.jpg" alt="Make your own free website on Tripod.com" style="border:0; display:block; " /> </a> <div id="footerAd_container" style="display:block!important; float:left; width:728px"> <script type="text/javascript">document.write(lycos_ad['leaderboard2']);</script> </div> </div> </div> <noscript> <img src="http://members.tripod.com/adm/img/common/ot_noscript.gif?rand=379875" alt="" width="1" height="1" />  <iframe frameborder="0" marginwidth="0" marginheight="0" scrolling="no" width="728" height="90" src="http://ad.yieldmanager.com/st?ad_type=iframe&ad_size=728x90&section=209094"></iframe>  </noscript> <form action="url" method="get"> <div align="center"> <input type="image" src="rainbow.gif" name="image" width="60" height="60"><br> <b>LOG IN NAME AND PASSWORD</b> <br> <i>maximum of 15 chracters only</i><br> <b>Username:</b> <input type="text" value="username please" maxlength="15"><p> <i>maximum of 8 chracters only</i><br> <b>Password:</b> <input type="password" maxlength="8"><p> <b>Confirm password:</b> <input type="password" maxlength="8"><p> <br> <b>PERSONAL INFORMATION</b> <br> <b>First name:</b> <input type="text" size="50"><p> <b>Last name:</b> <input type="text" size="50"><p> <b>Sex:</b> <input type="radio" name="group1" value="Male" checked> Male <input type="radio" name="group1" value="Female"> Female<br> <b>Street:</b> <textarea cols="40" rows="5" name="myname"></textarea><br> <b>City:</b> <input type="text" value="Manila" size="25"><p> <b>State:</b> <select name="mydropdown"> <option value="AL">AL</option> <option value="AK">AK</option> <option value="AZ">AZ</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IL">IL</option> <option value="IN">IN</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option> <option value="PR">PR</option></select> <br> <b>Non-US State:</b> <input type="text" size="25"><p> <b>Postal Code:</b> <input type="text" size="10"><p> <b>Country:</b> <input type="text" size="30"><p> <b>Birth Date:</b> <select name="mydropdown" value="choose month"> <option value="January">January</option> <option value="February">February</option> <option value="March">March</option> <option value="April">April</option> <option value="May">May</option> <option value="June">June</option> <option value="July">July</option> <option value="August">August</option> <option value="September">September</option> <option value="October">October</option> <option value="November">November</option> <option value="December">December</option> </select> <select name="mydropdown"> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> <option value="11">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">16</option> <option value="17">18</option> <option value="19">20</option> <option value="21">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> <input type="text" value="year" maxlength="4" size="3"><p> <b>Email Address:</b> <input type="text" value="type your Email Adress here" size="25"><p> <br><input type="submit" value="Send me your form!"> <input type="reset" value="Reset!"><br> </form> </body> </html>