<table width="70%" border="1" align="center" cellpadding="0" cellspacing="10" bordercolor="#000000">
<tr>
<td><div align="center">
<p><img src="http://oilregionbusiness.com/images/letterhead.png" width="450" height="120" /></p>
</div></td>
</tr>
<tr>
<td><div align="center">
<!-- /shadowblock_out -->
</div>
</div>
<h2 align="center" class="dotted"><span class="shadowblock">Business Information </span></h2> <div align="left">
<form id="form1" name="form1" method="post" action="">
<label>Company Name
<input name="textfield" type="text" size="50" maxlength="255" />
</label>
<label>Owner Name
<input name="textfield22" type="text" size="40" maxlength="255" />
</label>
<p>
<label></label>
<label>Contact Person
<input name="textfield112" type="text" size="50" maxlength="255" />
</label>
</p>
<p>
<label></label>
<label>Street
<input name="textfield32" type="text" size="40" maxlength="255" />
</label>
<label>City
<input name="textfield42" type="text" size="25" maxlength="255" />
</label>
<label>Zipcode
<input name="textfield52" type="text" size="15" maxlength="20" />
</label>
<label>State
<input name="textfield62" type="text" size="20" maxlength="255" />
</label>
</p>
<p>
<label></label>
<label>Telephone
<input name="textfield72" type="text" size="30" maxlength="20" />
</label>
<label>Fax
<input name="textfield82" type="text" size="30" maxlength="20" />
</label>
<label>Email
<input name="textfield92" type="text" size="45" maxlength="255" />
</label>
</p>
<p>
<label></label>
<label>Website (If Available)
<input name="textfield102" type="text" size="50" maxlength="255" />
</label>
</p>
</form>
</div></td>
</tr>
<tr>
<td><div align="center">
<h2>Business Description</h2>
</div></td>
</tr>
<tr>
<td valign="middle"><div align="justify">
<p> </p>
<form id="form2" name="form2" method="post" action="">
<label>About Your Business
<br />
<textarea name="textfield12" cols="100"></textarea>
</label>
<p>
<label>Products and/or Services
<br />
<textarea name="textfield13" cols="95"></textarea>
</label>
</p>
<p>
<label>Motto
<br />
<textarea name="textfield14" cols="100"></textarea>
</label>
<br />
</p>
</form>
</div></td>
</tr>
<tr>
<td valign="middle"><div align="center">Submit Form </div></td>
</tr>
</table>
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