<td align=center>
<form action="sendmail.php" method=post  name='text'>
<table border=0>
<tr> <td colspan=2 align=center> <b><u>Форма заявки</u></b><br>
  <br> <font color=red>*</font> обязательны для заполнения   <br> <br> </td>
</tr>  <!-- STRING AUTHORIZATION FIELDS (LOGIN, PASSWORD) -->            
  <!-- GENERAL INFORMATION (FIRST NAME, LAST NAME, EMAIL ) -->
      <tr>     <td colspan=2 align=center> <table bgcolor=#B2D1F5 width=80%>
                            <tr>
  <td> <font color=black class=small> ИНФОРМАЦИЯ О ПОКУПАТЕЛЕ </font> </td>
                            </tr>
                          </table></td>
                      </tr>
                      <tr>
                        <td width="174" align=right> <font color=red>*</font>
      Наименование товара: </td>
        <td> <textarea name="text" rows=4 onchange='name'></textarea>
                        </td>
                      </tr>
                      <tr>
<td align=right> <input name="affiliationLogin" type="hidden" value="" />
<font color=red>*</font> Имя: </td>
<td width="179"> <input type="text" name="first_name"
                value=""> </td>
                      </tr>
                      <tr>
<td align=right> <font color=red>*</font> Фамилия: </td>
<td> <input type="text" name="last_name"
                value=""> </td>
                      </tr>
                      <tr>
<td align=right> <font color=red>*</font> Email: </td>
<td> <input type="text" name="email" value=""> </td>
                      </tr>                
<!-- ADDITIONAL FIELDS (SEE  admin.php?dpt=custord&sub=reg_fields URL) -->
      <tr>
<td align=right> <font color=red>*</font> Контактный телефон:
                    </td>
<td> <input type='text' name='additional_field_1' value=''> </td>
                      </tr>
                      <tr>
<td colspan=2 align=center> <table bgcolor=#B2D1F5 width=80%>
        <tr>
  <td> <font color=black class=small> АДРЕС </font>
                              </td>
                            </tr>
                          </table></td>
                      </tr>
      <!-- DELIVERY ADDRESS (COUNTRY, AREA(STATE), INDEX, CITY, ADDRESS) -->
        <tr>
        <td colspan=2 align=center> <table border=0>
                            <tr>
<td align=right> <font color=red>*</font> Город:
                              </td>
<td> <input type="text" name="city" value="" nblur='java script:billingAddressCheckHandler()' onchange='java script:billingAddressCheckHandler()' > </td>
                            </tr>
                            <tr>
     <td align=right> <font color=red>*</font> Область:
                              </td>
    <td> <input type="text" name="state" value="" onchange='java script:billingAddressCheckHandler()' >
                              </td>
                            </tr>
                          </table>
                          <script language='JavaScript'>
            function billingAddressCheckHandler()
            {
                return;
            }
            </script> </td>
                    </table>


        <script language='JavaScript'>

        function changeCountryHandler()
        {
                document.RegisterForm.submit();
        }

        </script>


<p>
<input type="submit" value="OK" name=save>


<input type=reset value="Очистить">
</p>



</form>