DMH/DD/SAS NCI Instructor List Feedback</h1> <hr SIZE="5"> <form METHOD="POST" ACTION="feedback.idc"> <table> <tr><td ALIGN="left" VALIGN="top" COLSPAN="3"><font SIZE="+1" COLOR="RED" FACE="HUMANST521 BT"><b>Your Name and Address (Optional but Helpful)</b></font></td></tr> <tr><td><img SRC="images/spacer1.gif" WIDTH="36" HEIGHT="14"></td><td ALIGN="left" VALIGN="top" WIDTH="25">Name<td ALIGN="left" VALIGN="top"><input NAME="Name" TYPE="text" SIZE="45,1"></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">Organization<td ALIGN="left" VALIGN="top"><input NAME="Organization" TYPE="text" SIZE="45,1" MAXLENGTH="50"></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">Address1<td ALIGN="left" VALIGN="top"><input NAME="Address1" SIZE="45"></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">Address2<td ALIGN="left" VALIGN="top"><input NAME="Address2" SIZE="45"></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">City,State Zip<td ALIGN="left" VALIGN="top"><input NAME="City" SIZE="25"><input NAME="State" SIZE="2"><input NAME="Zip" SIZE="10"></td></tr> <tr><td ALIGN="left" VALIGN="top" COLSPAN="3"><font SIZE="+1" COLOR="RED" FACE="HUMANST521 BT"><b>Other Methods of Contacting You! (Optional but Helpful)</b></font></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">Phone</td><td><input NAME="Phone" SIZE="15"></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">Fax</td><td><input NAME="Fax" SIZE="15"></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top">EMail</td><td><input NAME="EMail" SIZE="45"></td></tr> </table> <table> <tr><td ALIGN="left" VALIGN="top" COLSPAN="2"><font SIZE="+1" COLOR="RED" FACE="HUMANST521 BT"><b>How Did You Reach Us?</b></font></td></tr> <tr><td><img SRC="images/spacer1.gif" WIDTH="36" HEIGHT="14"></td><td ALIGN="left" VALIGN="top"> <input NAME="Connect" TYPE="radio" VALUE="Modem" CHECKED>Via Modem and Internet Provider<br><input NAME="Connect" TYPE="radio" VALUE="LAN">Via LAN or Other High Speed Connection</td></tr> <tr><td ALIGN="left" VALIGN="top" COLSPAN="2"><font SIZE="+1" COLOR="RED" FACE="HUMANST521 BT"><b>How Did You Here About Us?</b></font></td></tr> <tr><td></td><td ALIGN="left" VALIGN="top"><input NAME="HereAbout" TYPE="radio" VALUE="Division" CHECKED>Told By Division Staff<br><input NAME="HereAbout" TYPE="radio" VALUE="Non-Division">Told by Other Non-Division Staff<br><input NAME="HereAbout" TYPE="radio" VALUE="Other">Other Method</td></tr> <tr><td></td><td ALIGN="left" VALIGN="top"><input NAME="browser" TYPE="text" SIZE="25"> Browser Name and Version <tr><td ALIGN="left" VALIGN="top" COLSPAN="2"><font SIZE="+1" COLOR="RED" FACE="HUMANST521 BT"><b>Tell Us What You Think About Our Calendar!<br>Comments and/or Suggestions</b></font></td></tr> <tr><td></td><td><textarea NAME="Comments" ROWS="5" COLS="55" WRAP="VIRTUAL"></textarea></td></tr>  </table> <table> <tr> <td VALIGN="top"><input TYPE="submit" VALUE="Mail It"></td> <td><input TYPE="reset" VALUE="Clear Form"></form></td> </tr> </table> <a HREF="index.htm"><img SRC="images/back.gif" WIDTH="20" HEIGHT="20">Return to Search</a> </body> </html>