ÿþ<html> <!-- Created on: 27/10/2009 --> <head><script src="/A2EB891D63C8/avg_ls_dom.js" type="text/javascript"></script> <meta http-equiv="Content-Type" content="text/html; charset=windows-1252"> <title></title> <meta name="description" content=""> <meta name="keywords" content=""> <meta name="author" content="Wolfgang Johansson"> <meta name="generator" content="AceHTML 6 Pro"> </head> <body bgcolor="#008080" text="#000000" link="#0000ff" vlink="#800080" alink="#ff0000" topmargin="30" marginheight="30"> <table width=800 border=1 align=center bgcolor=#FFFFCC bordercolor=#000000 summary=""> <tr> <td><div style="text-align: center"><font size="5" color="#800000"><b>WALLANGULLA MOTEL BOOKING FORM</b></font></div><p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p><div style="text-align: center"><a href="http://www.wallangulla.com/">Click Here to Return to Wallangulla Motel Main Page</a></div></td> </tr> <tr> <td><table border="0" align="center" bordercolor="#0000FF" > <tr> <td><FORM METHOD=POST ACTION="../cgi-bin/formmail/FormMail.pl"> <INPUT type=hidden name="recipient" value="wall@lrbc.com.au"> <BR> <INPUT type=hidden name="subject" value="Form Submitted Email"> <BR><FONT face="Verdana, Arial, Helvetica" size=3><U><B>Enter Your Personal Data :</B></U></FONT><P><CENTER><TABLE border=0 cellSpacing=1 width="90%"> <TBODY> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Name </FONT></TD> <TD><INPUT maxLength=50 name=UserName size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Company </FONT></TD> <TD><INPUT maxLength=100 name=UserCompany size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Street </FONT></TD> <TD><INPUT maxLength=150 name=UserStreet size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>City </FONT></TD> <TD><INPUT maxLength=100 name=UserCity size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Country </FONT></TD> <TD><INPUT maxLength=75 name=UserCountry size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Phone </FONT></TD> <TD><INPUT maxLength=35 name=UserTel size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Fax </FONT></TD> <TD><INPUT maxLength=35 name=UserFax size=35> </TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>E-mail </FONT></TD> <TD><INPUT maxLength=70 name=UserEmail size=35><PRE></PRE></TD></TR></TBODY></TABLE></CENTER><!--xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx--><P><FONT face="Verdana, Arial, Helvetica" size=3><U><B>Specify Room Type of Accommodation: </B></U></FONT><P><CENTER><TABLE border=0 cellSpacing=1 width="90%"> <TBODY> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2><U><B>Room Type</B></U> </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><U><B>Number of Rooms Wanted </B></U> </FONT></TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2> Potch Court </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=Potch Court size=1> <OPTION selected value=0>0</OPTION> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION></SELECT> </FONT>3 Star</TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Gem Court </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=Gem Court size=1> <OPTION selected value=0>0</OPTION> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION> </SELECT> </FONT>3 Star</TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Family Room </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=Family Room size=1> <OPTION selected value=0>0</OPTION> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION> </SELECT> </FONT>3 Star</TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Bridal Room </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=Bridal Room size=1> <OPTION selected value=0>0</OPTION> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION> </SELECT> </FONT>3 Star</TD></TR></TBODY></TABLE></CENTER><!--xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx--><P><FONT face="Verdana, Arial, Helvetica" size=3><U><B>Specify Number OfRooms Of Each Type :</B></U> </FONT><P><CENTER><TABLE border=0 cellSpacing=1 width="90%"> <TBODY> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2><U><B>Persons</B></U> </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><U><B>Number Persons</B></U> </FONT></TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Adults </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=Adults size=1> <OPTION selected value=0>0</OPTION> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION></SELECT> </FONT></TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Children </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=Children size=1> <OPTION selected value=0>0</OPTION> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION> </SELECT> </FONT></TD></TR> </TBODY></TABLE></CENTER><P><FONT face="Verdana, Arial, Helvetica" size=3><U><B>Enter Arrival AndDeparture Dates :</B></U> </FONT><P><CENTER><TABLE border=0 cellSpacing=1 width="90%"> <TBODY> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Arrival Date </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=arrivalday size=1> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION> <OPTION value=11>11</OPTION> <OPTION value=12>12</OPTION> <OPTION value=13>13</OPTION> <OPTION value=14>14</OPTION> <OPTION value=15>15</OPTION> <OPTION value=16>16</OPTION> <OPTION value=17>17</OPTION> <OPTION value=18>18</OPTION> <OPTION value=19>19</OPTION> <OPTION value=20>20</OPTION> <OPTION value=21>21</OPTION> <OPTION value=22>22</OPTION> <OPTION value=23>23</OPTION> <OPTION value=24>24</OPTION> <OPTION value=25>25</OPTION> <OPTION value=26>26</OPTION> <OPTION value=27>27</OPTION> <OPTION value=28>28</OPTION> <OPTION value=29>29</OPTION> <OPTION selected value=30>30</OPTION> <OPTION value=31>31</OPTION></SELECT> <SELECT name=arrivalmonth size=1> <OPTION value=January>January</OPTION> <OPTION value=February>February</OPTION> <OPTION value=March>March</OPTION> <OPTION value=April>April</OPTION> <OPTION selected value=May>May</OPTION> <OPTION value=June>June</OPTION> <OPTION value=July>July</OPTION> <OPTION value=August>August</OPTION> <OPTION value=September>September</OPTION> <OPTION value=October>October</OPTION> <OPTION value=November>November</OPTION> <OPTION value=December>December</OPTION></SELECT> <SELECT name=arrivalyear size=1><OPTION selected value=2012>2012</OPTION> <OPTION value=2013>2013</OPTION> <OPTION value=2014>2014</OPTION> <OPTION value=2015>2015</OPTION> <OPTION value=2016>2016</OPTION> </SELECT> </FONT></TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Approx. Arrival Time </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><INPUT maxLength=15 name=arrivaltime size=13>(time) </FONT></TD></TR> <TR> <TD width="30%"><FONT face="Verdana, Arial, Helvetica" size=2>Departure Date </FONT></TD> <TD><FONT face="Verdana, Arial, Helvetica" size=2><SELECT name=departureday size=1> <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> <OPTION value=9>9</OPTION> <OPTION value=10>10</OPTION> <OPTION value=11>11</OPTION> <OPTION value=12>12</OPTION> <OPTION value=13>13</OPTION> <OPTION value=14>14</OPTION> <OPTION value=15>15</OPTION> <OPTION value=16>16</OPTION> <OPTION value=17>17</OPTION> <OPTION value=18>18</OPTION> <OPTION value=19>19</OPTION> <OPTION value=20>20</OPTION> <OPTION value=21>21</OPTION> <OPTION value=22>22</OPTION> <OPTION value=23>23</OPTION> <OPTION value=24>24</OPTION> <OPTION value=25>25</OPTION> <OPTION value=26>26</OPTION> <OPTION value=27>27</OPTION> <OPTION value=28>28</OPTION> <OPTION value=29>29</OPTION> <OPTION value=30>30</OPTION> <OPTION selected value=31>31</OPTION></SELECT> <SELECT name=departuremonth size=1> <OPTION value=January>January</OPTION> <OPTION value=February>February</OPTION> <OPTION value=March>March</OPTION> <OPTION value=April>April</OPTION> <OPTION selected value=May>May</OPTION> <OPTION value=June>June</OPTION> <OPTION value=July>July</OPTION> <OPTION value=August>August</OPTION> <OPTION value=September>September</OPTION> <OPTION value=October>October</OPTION> <OPTION value=November>November</OPTION> <OPTION value=December>December</OPTION></SELECT> <SELECT name=departureyear size=1> <OPTION value=2012>2012</OPTION> <OPTION value=2013>2013</OPTION> <OPTION value=2014>2014</OPTION><OPTION value=2015>2015</OPTION> <OPTION value=2016>2016</OPTION> </SELECT></FONT></TD></TR></TBODY></TABLE></CENTER><P><P><FONT face="Verdana, Arial, Helvetica" size=3>Specify SpecialRequests Or Comments : </FONT><P><P><TEXTAREA cols=62 name=comment rows=5></TEXTAREA></P><FONTface="Verdana, Arial, Helvetica" size=3>Specify How The Motel Should ConfirmThis Reservation Or Send The Requested Information : </FONT><BLOCKQUOTE> <P><SELECT name=ConfirmMenu size=1> <OPTION selected>Email</OPTION> <OPTION selected>Fax</OPTION> <OPTION>Phone</OPTION> <OPTION>Mail</OPTION></SELECT></P></BLOCKQUOTE><FONTface="Verdana, Arial, Helvetica" size=3>Continue Here : </FONT><P>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<INPUT type=submit value="Create Form">OR <INPUT type=reset value="Clear Form"></P></FORM></td> </tr></table> </td> </tr> </table> </body> </html>