<html>

<head>
<title>Safelist Form</title>
</head>

<body bgcolor="#FFFFFF">
<div align="center">
  <center>
    <table width="100%" cellspacing="0" cellpadding="0" background="">
      <tr> 
        <td width="100"><a href="/safelist.shtml"><img src="/images/Lifetime.gif" border="0" alt="Click Our Logo To Go To Safelist Home Page"></a></td>
        
      </tr>
    </table>
    <table width="100%" cellspacing="0" cellpadding="0">
      <tr> 
        <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#0000FF">Changing 
          info </font></td>
        <td> 
          <div align="right"><font face="Verdana, Arial, Helvetica, sans-serif" color="#0000FF">SafeList 
            Pro</font></div>
        </td>
      </tr>
    </table>
  </center>
</div>
<font face="Verdana, Arial, Helvetica, sans-serif"> 
<p align="center"><font color="#FF0000"><i> </i></font></p>
</font> 
<p align="center"><font color="#FF0000" face="Verdana, Arial, Helvetica, sans-serif"><i>All 
  Fields Required </i></font></p>
<p align="center"> <font face="Verdana, Arial, Helvetica, sans-serif" color="#3300FF" size="2">NOTE:</font><font face="Verdana, Arial, Helvetica, sans-serif" size="2"> 
  Your Email Address is where your</font> <font face="Verdana, Arial, Helvetica, sans-serif" size="2">Login 
  info will be sent.</font> </p>
<p align="center"> <font face="Verdana, Arial, Helvetica, sans-serif" size="2">In 
  the event you lose your password</font> <font face="Verdana, Arial, Helvetica, sans-serif" size="2">You 
  will be asked for your Username & Birthdate</font><font
face="Verdana, Arial, Helvetica, sans-serif">.</font> </p>
<form METHOD="post" action="main.cgi">
<input type="hidden" name="user" value="[USER]"><!--DO'T REMOVE-->
<input type="hidden" name="pass" value="[PASS]"><!--DO'T REMOVE-->
  <table WIDTH="400" ALIGN="center">
    <tr> 
      <td>
        <table ALIGN="center">
          <tr> 
            <td ALIGN="right"><font face="Courier New" color="#0000FF">First Name:</font> 
            </td>
            <td>
              <input TYPE="text" NAME="firstname" size="20" value="[FIRSTNAME]">
            </td>
          </tr>
          <tr> 
            <td ALIGN="right"><font color="#0000FF" face="Courier New, Courier">Last 
              Name: </font></td>
            <td>
              <input TYPE="text" NAME="lastname" size="20" value="[LASTNAME]">
            </td>
          </tr>
          <tr> 
            <td ALIGN="right"><font color="#0000FF" face="Courier New, Courier">Email 
              Address:</font> </td>
            <td>
              <input TYPE="text" NAME="email" size="20" value="[EMAIL]">
            </td>
          </tr>
          <tr> 
            <td ALIGN="right"><font color="#0000FF" face="Courier New, Courier">Username:</font></td>
            <td>
              <input TYPE="text" NAME="username" size="20" value="[USERNAME]">
            </td>
          </tr>
          <tr> 
            <td ALIGN="right"><font color="#0000FF" face="Courier New, Courier">Password: 
              </font></td>
            <td>
              <input TYPE="password" NAME="password" size="20" value="[PASS]">
            </td>
          </tr>
          <tr> 
            <td ALIGN="right"><font color="#0000FF" face="Courier New, Courier">Birthdate: 
              </font></td>
            <td>
              <input TYPE="text" NAME="DOB" size="20" value="[DOB]">
              <font size="1" color="#FF0000">DD/MM/YYYY</font> </td>
          </tr>
          <tr> 
            <td COLSPAN="2" ALIGN="center">
              <input TYPE="submit" NAME="action" VALUE="Change">
            </td>
          </tr>
        </table>
      </td>
    </tr>
  </table>
</form>
<p align="center"> </p>
<p align="center"><font face="Verdana, Arial, Helvetica, sans-serif" size="1"></font></p>
</body>
</html>
