<FORM ACTION="/cgi-bin/FormMail.pl" METHOD="POST" NAME="FormNo1">
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<TD COLSPAN="3" BGCOLOR="#ffffff" > </TD>
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<TD WIDTH="20%"> </TD>
<TD WIDTH="10%">Name:</TD>
<TD WIDTH="70%"> <INPUT TYPE="text" SIZE="35" NAME="Name" onChange="capWords(this)"></TD>
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<TR>
<TD> </TD>
<TD>Address:</TD>
<TD><INPUT TYPE="text" NAME="Address1" SIZE="50" onChange="capWords(this)"></TD>
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<TD> </TD>
<TD>Address2:</TD>
<TD><INPUT TYPE="text" NAME="Address2" SIZE="50" onChange="capWords(this)"></TD>
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<TD> </TD>
<TD>City:</TD>
<TD><INPUT TYPE="text" NAME="City" SIZE="50" onChange="capWords(this)"></TD>
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<TD> </TD>
<TD>State:</TD>
<TD><INPUT TYPE="text" NAME="State" SIZE="25"></TD>
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<TD> </TD>
<TD>Zip:</TD>
<TD><INPUT TYPE="text" NAME="Zip" SIZE="25"></TD>
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<TD> </TD>
<TD>Country:</TD>
<TD><INPUT TYPE="text" NAME="Country" SIZE="25" onChange="capWords(this)"></TD>
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<TD> </TD>
<TD>Telephone:</TD>
<TD><INPUT TYPE="text" NAME="Phone" SIZE="25" onChange="formatPhone(this)"></TD>
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<TD> </TD>
<TD>Email:</TD>
<TD><INPUT TYPE="text" SIZE="35" NAME="Email" onChange="clearTrailingSpace(this)"></TD>
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<TD COLSPAN="3" BGCOLOR="#ffffff" > </TD>
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<TD COLSPAN="3" BGCOLOR="#ffffff" ><BLOCKQUOTE>
<BLOCKQUOTE STYLE="margin-top: 0; margin-bottom: 0;">
<P STYLE="margin-top: 0; margin-bottom: 0;">Please note that we do
not share your private information with any other group or list</P>
</BLOCKQUOTE>
</BLOCKQUOTE></TD>
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<TR>
<TD COLSPAN="3" BGCOLOR="#ffffff" > </TD>
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<TR>
<TD COLSPAN="3" BGCOLOR="#CCCCCC" > </TD>
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<TR>
<TD COLSPAN="3" BGCOLOR="#ffffff" ALIGN="center"> <BR>
I would like to be on your mailing list:
<INPUT TYPE="radio" NAME="Do I want to be put on the mailing list?" VALUE="Yes" CHECKED> <B>Yes</B> <INPUT TYPE="radio" NAME="Do I want to be put on the mailing list?" VALUE="no"> <B>No</B> <BR> <BR>
I would like to be on your e-mail list to receive weekly updates:
<INPUT TYPE="radio" NAME="Do I want to be put on the email list?" VALUE="Yes" CHECKED> <B>Yes</B> <INPUT TYPE="radio" NAME="Do I want to be put on the email list?" VALUE="no"> <B>No</B> <BR> <BR>
I found out about you through:
<INPUT TYPE="text" NAME="I found you through" SIZE=30>
<BR>
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<TD COLSPAN="3" BGCOLOR="#CCCCCC" > </TD>
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<TABLE WIDTH="95%" BORDER="0" CELLSPACING="0" CELLPADDING="2" ALIGN="center">
<TR>
<TD WIDTH="50%" VALIGN="top" ALIGN="right"><BR>What are your interests?</TD>
<TD WIDTH="50%" BGCOLOR="#ffffff" CLASS="membershipmenu"><BR>
<INPUT TYPE="checkbox" NAME="My interests" VALUE="Retreats">
<B>Retreats?</B><BR>
<INPUT TYPE="checkbox" NAME="My interests include" VALUE="Ongoing meditation groups">
<B>Ongoing meditation groups?</B><BR>
<INPUT TYPE="checkbox" NAME="My interests include" VALUE="Hypnotherapy">
<B>Hypnotherapy and Counseling?</B><BR>
<INPUT TYPE="checkbox" NAME="My interests include" VALUE="Personal retreats?">
<B>Personal Retreats?</B><BR>
<INPUT TYPE="checkbox" NAME="My interests include" VALUE="Residency">
<B>Residency or long term stays?</B><BR>
<INPUT TYPE="checkbox" NAME="My interests include" VALUE="Five Changes">
<B>Help with the work of Five Changes Foundation?</B><BR>
<INPUT TYPE="checkbox" NAME="My interests include" VALUE="Other">
<B>Other?</B>
</TD>
</TR>
<TR>
<TD ALIGN="RIGHT" VALIGN="TOP"><BR>Do you have any previous experience in any of these areas?</TD>
<TD BGCOLOR="#ffffff" VALIGN="TOP"><BR><INPUT TYPE="text" NAME="This is my experience in these areas" SIZE=30><BR><BR></TD>
</TR>
<TR BGCOLOR="#CCCCCC">
<TD COLSPAN="2" ALIGN="center"> </TD>
</TR>
<TR>
<TD COLSPAN="2" BGCOLOR="#ffffff" ALIGN="center"><BR>
Would you like to become a member of Ordinary Dharma and Manzanita Village to support our work on a regular basis and receive membership rates for workshops and retreats?<BR>
<INPUT TYPE="radio" NAME="Do I want to become a member of Ordinary Dharma and Manzanita Village?" VALUE="Yes" CHECKED><B>Yes</B>
<INPUT TYPE="radio" NAME="Do I want to become a member of Ordinary Dharma and Manzanita Village?" VALUE="no"><B>No</B>
<BR>
<DIV CLASS="membershipmenu">(See <A HREF="/retreats/content_thevision.html" TARGET="_self">Retreats/The
Vision</A> for more details <A HREF="/retreats/content_thevision.html#Quick_Links_10">Membership</A>)</DIV>
<BR>
Would you like to give a one-time donation to help support our work?
<INPUT TYPE="radio" NAME="Do I want to make a one-time donation?" VALUE="Yes" CHECKED><B>Yes</B>
<INPUT TYPE="radio" NAME="Do I want to make a one-time donation?" VALUE="no"><B>No</B><BR>
(See <A HREF="/retreats/content_thevision.html" TARGET="_self">Retreats/The
Vision</A> for more details <A HREF="/retreats/content_thevision.html#Quick_Links_9">Dana</A>)<BR>
</TD>
<TR BGCOLOR="#CCCCCC">
<TD COLSPAN="2" ALIGN="center"> </TD>
</TR>
<TR>
<TD ALIGN="CENTER" VALIGN="top" WIDTH="50%" BGCOLOR="CCCCCC">
<P STYLE="margin-top: 0; margin-bottom: 0"><BR>
Methods of payment: </P>
<P STYLE="margin-top: 0; margin-bottom: 0;"><A HREF="/resources2/content_registration.html"><SPAN STYLE="background-color: #FFFF00">Online
Submission by Credit Card through PayPal </SPAN></A></P>
<P STYLE="margin-top: 0; margin-bottom: 0;"><BR>
or mail your check to:<BR>
<B>Ordinary Dharma, <BR>
PO Box 67,<BR>
Warner Springs,<BR>
CA 92086, USA</B> </P></TD>
<TD ALIGN="CENTER" WIDTH="50%" BGCOLOR="CCCCCC">Other Comments:<BR>
<TEXTAREA NAME="Other comments" COLS="30" ROWS="7"></TEXTAREA>
<BR>
<BR>
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<INPUT TYPE=hidden NAME="recipient" VALUE="manzanita@ordinarydharma.org">
<INPUT TYPE=hidden NAME="redirect" VALUE="http://www.manzanitavillage.org/resources/content_thankyou.html">
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