
<form title='Discount registration' method='POST' action='coupon.php' onsubmit='return validate(this)'>
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<table  width=100% ><tr><td  align=center> <h2  align=center bgcolor=red>Register to Receive your  <font color=red><b>Discount</b></font> Coupon</h2>
<p>This High Value Office is made exclusively to Internet Clients of the Portsmouth office.  This office is exclusive to registered users and is not transferable. </p>
<p>Please Validate your Coupon Below:
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	<table  align=center height=100% bgcolor=#0795FA  ><tr><td colspan=3 class=coupon></td></tr><tr><td class=coupon></td><td><table><tr><td><b> First Name:</b></td><td><input type='text' name='FirstName'  onchange=update(this.value,name); size='15'></td><td>Last Name:</td><td><input onchange=update(this.value,name); type=text name='LastName' size=15></td></tr><tr><td><b>Phone:</b></td><td><input type='text' name='phone' size=12 ></td><td>Address</td><td><input type=text name=address></td></tr><tr><td><b>Email:</b></td><td><input size=10 type=text name='email'></td><td colspan=2> <input type=submit name='B1' value='Register'></td></tr><tr><td> Your Coupon Number is: 201203311603<input type=hidden name=coupon value=201203311603></td><td></td><td colspan=2>  Date: 03/31/2012 4:04</td></form>
</tr></table></td><td class=coupon></td></tr><tr><td class=coupon colspan=3></td></tr></table><td></td></tr><tr><td align=center>201203311603<div style='z-index: 200; left; position: relative; width: 300px;'>
<table><tr><td bgcolor=red><u>Instructions</U><br>Please Print, Then Bring this Coupon to Your Consultation with Valid ID to Redeem.</td><td>
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<table bgcolor=white border=1><tr><td colspan=2><img  width=230  align=left src=consultation.jpg>The Law Offices of Steve C Taylor<br><blockquote>522 S. Independance Blvd, Virginia Beach, VA 23452</blockquote><br>Coupon Number: <input type=text id=couponnumber value=201203311603></td></tr><tr><td>Coupon Status:</td><td id=status>Unregistered</td></tr><tr><td colspan=2><img align=left src=bc.php?code=201203311603><b><font color=red size=+2>Offer Details: Free Consulation </font></b><table><tr><td id=FirstName></td><td id=LastName></td></tr></table></td></tr></table></td></tr></table></div></div> </td></tr></table></form></div>