Dig Print on line

<form method="POST"action="http://www.ieasysite.com/CGI-SHL/CGIShEll.EXE?REPLYTOVENDOR">
<input type="hidden" name="Recipient" value="Orders@eapphoto.com">
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<b>Customer Information</b>
First Name: <input type="text" name="First Name" size="10"> Last Name: <input type="text" name="Last Name" size="20">
**Store Name: <input type="text" name="**Store Name" size="15"> **Account#: <input type="text" name="**Account #" size="9"> <b>Wholesaler Use Only</b>
Area Code: <input text="text" name="Area Code" size="3"> Phone Number: <input type="text" name="Phone Number" size="7">
<tr>
<td>E-Mail: </td>
<td><input type="text" size="40" name="Email"></td>
</tr>
<b>Order Information</b>
**Bag#: <input type="text" name="**Bag #" size="7"> <b>Wholesaler Use Only</b>
List your order information to the right: <textarea name="List your order information to the right" cols="30" rows ="7" ></textarea>
List File Name, Quantity of prints and Print Size (Ex. 1-8x10 of #12)
<b>LIMIT OF 6 CHARACTERS PER FILE NAME</b>

<b>Delivery Options</b>
Do you want your order shipped or will you pick it up in our store?: <input text="text" name="Do you want your order shipped or will you pick it up in our store?" size ="6">
<b>Indicate "ship" or "pickup"</b>

<b>Shipping Information</b>
Street Address: <input type="text" name="Street Address" size="40">
City: <input type="text" name="City" size="15"> State: <input type="text" size="2" name="State"> Zip: <input type="text" size="5" name="Zip">

<b>Payment Information</b>
Credit Card: <input type="text" name="Credit Card" size="19"> Exp Date: <input type="text" name="Expiration Date" size="5">
<b>ORDERS WILL NOT BE PROCESSED WITHOUT A VALID CREDIT CARD NUMBER</B>

Comments:
<textarea name="Comments" cols="40" rows="8"></textarea>
<input type=submit value="Submit" name="Submit"><input type=reset name="reset">
<b>DONT FORGET TO EMAIL YOUR FILES TO ORDERS@EAPPHOTO.COM</b>
<color=#FF0000>You will receive an email response when your order has been received. </color=#FF0000>
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</form>