ÿþ<HTML> <HEAD> <TITLE>Aquatic rehab training center - course registration</TITLE> <META name="description" content="Registration form for Aquatic Rehab Training Center classes"> <META name="keywords" content="aquatic rehab training center classes, aquatic rehab"> <META name="MSSmartTagsPreventParsing" content="TRUE"> <LINK rel=stylesheet href="me.css"> <SCRIPT TYPE="text/javascript" LANGUAGE="JavaScript"> <!-- if (top.frames.length > 1) { top.location="http://www.maryessert.com/registration2.htm?status=deframed"; } // --> </SCRIPT> </HEAD> <BODY bgColor="#C1FFE0"> <CENTER> <TABLE border=0 cellPadding=0 cellSpacing=0 width="800" bgColor="#9BD2FB"> <TR> <TD width="800" height="93" vAlign="top" background="./images/toppanel.gif" border=0><p>&nbsp;</p> </TD> </TR> <TR bgColor="aqua"> <TD width="800" vAlign="top" bgcolor="#ABFCC6"> <font size="+1" color=#000000 face="Arial,Helvetica"> <a href="artc.htm">home</a> | <a href="curic.htm">course listing</a> | <a href="faq.htm">faq</a> | <a href="contact.htm">contact</a><br> </font> </TD> </TR> </TABLE> <TABLE border=0 cellPadding=0 cellSpacing=0 width="800" bgColor="#C1FFE0"> <TR><TD><br></TD></TR> </TABLE> <!-- CONTENT START --> <TABLE border=0 cellPadding=0 cellSpacing=0 width="800"> <TR> <TD bgColor="#ABFCC6"> <DIV class=homepglinks><br> <font size="+2" color=#000000 face="Arial,Helvetica">Course Registration</font><br><br> <FORM method="post" action="http://www.maryessert.com/cgi-bin/mailto"> <INPUT TYPE="HIDDEN" name="recipient" VALUE="messert@mindspring.com"> <INPUT TYPE="HIDDEN" name="redirect" VALUE="http://www.maryessert.com/registration_thankyou.htm"> <TABLE> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Course name:</B></TD> <TD><INPUT type="text" name="course_name" size="42"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Name:</B></TD> <TD><INPUT type="text" name="registration_name" size="32"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Address:</B></TD> <TD><INPUT type="text" name="registration_address" size="32"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>City:</B></TD> <TD><INPUT type="text" name="registration_city" size="32"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>State/Prov.:</B></TD> <TD><INPUT type="text" name="registration_state" size="16"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Zip:</B></TD> <TD><INPUT type="text" name="registration_zip" size="16"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Country:</B></TD> <TD><INPUT type="text" name="registration_country" size="16"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Email:</B></TD> <TD><INPUT type="text" name="registration_email" size="16"></TD></TR> <TR> <TD>&nbsp;&nbsp;&nbsp;<B>Daytime Phone:</B></TD> <TD><INPUT type="text" name="registration_phone" size="16"></TD></TR> <TR> <TD><BR></TD> <TD><input type="submit" value="Submit">&nbsp; <input type="reset" value="Clear Form"><br></TD></TR> </TABLE> </FORM> <font size="2" color=#000000 face="Arial,Helvetica"> Please mail check or money order for $35.00, made out to Essert Associates, to:<br><br> Essert Associates<br> 3635 Irby Drive<br> Conway, AR 72034<br><br> Once we have processed your order, we will email you your User ID and Password. You will need this to Log-In to begin taking your class.<p> Your User ID and Password expire upon completion of your online course exam found at the end of the course materials.<br><br> </font> </TD> </TR> </TABLE> <!-- CONTENT END --> <TABLE border=0 cellPadding=0 cellSpacing=0 width="800" bgColor="#C1FFE0"> <TR> <TD> <br> <center><FONT color=#000000 face="Arial,Helvetica" size=1> © 2001 - 20012 Essert Associates. All Rights Reserved. Conway, AR 72032. (501) 505-8601 <br><br> </FONT></center> </TD> </TR> </TABLE> </CENTER> </BODY> </HTML>