Free Trial Application

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=215 BGCOLOR="#990000" TEXT="#F7F7FF"> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="Wachusett Fitness"><U><I><B>Home</B></I></U></A></div> <bR> <bR> </td> <td valign="top" colspan=2 height=80 BGCOLOR="#990000" TEXT="#F7F7FF"> <bR> <div> <I><B>Free Trial Application</B></I></div> <bR> <bR> <div> </div> </td> </tr><tr> <td valign="top" height=400 colspan=2 BGCOLOR="#FFFF80" TEXT="#080000"> <div> <B>Complete this form so we can contact you to arrange a trial membership that works best for you.</B></div> <div> <I><B> <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,LastName,Email,Address1,City,Phone,Age,Interest"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request. A member of our team will be in touch with you."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A free trial request form was submitted"><input type="hidden" name="tlx_EmailTo" value="paul@wachusettfitness.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">First Name:<br> <input type="text" name="FirstName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Last Name:<br> <input type="text" name="LastName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Age:<br> <input type="text" name="Age" size="3" maxlength="2"></td> </tr> <tr> <td align="left">Briefly tell us your fitness goals if you'd like.:<br> <textarea name="Interest" rows="5" cols="30"></textarea></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </B></I></div> </td> </tr></table></body>