<table width="100%" border="0" cellspacing="0" cellpadding="0">

                                      <tr>

                                        <td><form name="form1" method="post" action="http://net-shapers.com/unarxcardcreator/createdrugcardtemplate-restat.php">

        <table border="0" align="center" cellpadding="3" cellspacing="0">

          <tr>

            <td><table width="340" border="0" cellspacing="1" cellpadding="2" align="center" bgcolor="#000000">

                <tr bgcolor="#CCCCCC" align="center">

                  <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2"><b>Card

                    Information</b></font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">First

                    Name</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="firstName">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">Last

                    Name</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="lastName">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">Email</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="email">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF" align="center">

                  <td colspan="2"> <input type="submit" name="Submit" value="Create Prescription Card">

                  </td>

                </tr>

              </table></td>

          </tr>

          <tr>

            <td><center>

                <font size="1" face="Arial, Helvetica, sans-serif"><b><font face="Verdana, Arial, Helvetica, sans-serif">Note:

                You can put NONE in e-mail box if you don&#8217;t want updates.

                </font></b><br>

                &copy; Copyright 2006

                United Networks of America<br>

                Powered by <a href="http://net-shapers.com" target="_blank">NetShapers</a></font>

              </center></td>

          </tr>

        </table>

        <br>

                      <input name="franchise" type="hidden" value="3">

                                                              <input name="program" type="hidden" value="UNARxCard">

                                                              <input name="rxgrp" type="hidden" value="NARCUP">

                                                              <input name="fromaddress" type="hidden" value="EnterCompanysEmail@Address.Here">

                                                              <input name="disableAdditionalSavings" type="hidden" value="1">

                                                              <input name="disableReferralLogos" type="hidden" value="1">

                                                  </form></td>

                                                </tr>

                              </table>

<table width="100%" border="0" cellspacing="0" cellpadding="0">

                                      <tr>

                                        <td><form name="form1" method="post" action="http://net-shapers.com/unarxcardcreator/createdrugcardtemplate-restat.php">

        <table border="0" align="center" cellpadding="3" cellspacing="0">

          <tr>

            <td><table width="340" border="0" cellspacing="1" cellpadding="2" align="center" bgcolor="#000000">

                <tr bgcolor="#CCCCCC" align="center">

                  <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2"><b>Card

<table width="100%" border="0" cellspacing="0" cellpadding="0">

                                      <tr>

                                        <td><form name="form1" method="post" action="http://net-shapers.com/unarxcardcreator/createdrugcardtemplate-restat.php">

        <table border="0" align="center" cellpadding="3" cellspacing="0">

          <tr>

            <td><table width="340" border="0" cellspacing="1" cellpadding="2" align="center" bgcolor="#000000">

                <tr bgcolor="#CCCCCC" align="center">

                  <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="2"><b>Card

                    Information</b></font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">First

                    Name</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="firstName">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">Last

                    Name</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="lastName">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">Email</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="email">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF" align="center">

                  <td colspan="2"> <input type="submit" name="Submit" value="Create Prescription Card">

                  </td>

                </tr>

              </table></td>

          </tr>

          <tr>

            <td><center>

                <font size="1" face="Arial, Helvetica, sans-serif"><b><font face="Verdana, Arial, Helvetica, sans-serif">Note:

                You can put NONE in e-mail box if you don&#8217;t want updates.

                </font></b><br>

                &copy; Copyright 2006

                United Networks of America<br>

                Powered by <a href="http://net-shapers.com" target="_blank">NetShapers</a></font>

              </center></td>

          </tr>

        </table>

        <br>

                      <input name="franchise" type="hidden" value="3">

                                                              <input name="program" type="hidden" value="UNARxCard">

                                                              <input name="rxgrp" type="hidden" value="NARCUP">

                                                              <input name="fromaddress" type="hidden" value="EnterCompanysEmail@Address.Here">

                                                              <input name="disableAdditionalSavings" type="hidden" value="1">

                                                              <input name="disableReferralLogos" type="hidden" value="1">

                                                  </form></td>

                                                </tr>

                              </table>

                    Information</b></font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">First

                    Name</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="firstName">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">Last

                    Name</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="lastName">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF">

                  <td><font face="Arial, Helvetica, sans-serif" size="2">Email</font></td>

                  <td> <font face="Arial, Helvetica, sans-serif" size="2">

                    <input type="text" name="email">

                    </font></td>

                </tr>

                <tr bgcolor="#FFFFFF" align="center">

                  <td colspan="2"> <input type="submit" name="Submit" value="Create Prescription Card">

                  </td>

                </tr>

              </table></td>

          </tr>

          <tr>

            <td><center>

                <font size="1" face="Arial, Helvetica, sans-serif"><b><font face="Verdana, Arial, Helvetica, sans-serif">Note:

                You can put NONE in e-mail box if you don&#8217;t want updates.

                </font></b><br>

                &copy; Copyright 2006

                United Networks of America<br>

                Powered by <a href="http://net-shapers.com" target="_blank">NetShapers</a></font>

              </center></td>

          </tr>

        </table>

        <br>

                      <input name="franchise" type="hidden" value="3">

                                                              <input name="program" type="hidden" value="UNARxCard">

                                                              <input name="rxgrp" type="hidden" value="NARCUP">

                                                              <input name="fromaddress" type="hidden" value="EnterCompanysEmail@Address.Here">

                                                              <input name="disableAdditionalSavings" type="hidden" value="1">

                                                              <input name="disableReferralLogos" type="hidden" value="1">

                                                  </form></td>

                                                </tr>

                              </table>