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<title>※ 請確實填寫表單</title>
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<td colspan="2" bgcolor="#FF9999"> <p align="center"><b><font size="2" color="#008000">
<span style="background-color: #FFFF00">※ 請確實填寫表單，我們會儘快與您聯繫 <最高可申貸30萬元喔>
※</span></font></b></td>
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<FORM action=http://www.email104.com/cgi-bin/formmail/formemail.cgi?no=1064
method=post><INPUT type=hidden value=明我要申請代償方案_new貸 name=subject>
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<td colspan="2"> <table border="0" width="102%" cellspacing="0" cellpadding="0" id="table11" height="205">
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<td width="16%" align="right" height="35"> <font size="2">姓 名：</font></td>
<td width="28%" height="35"> <input type="text" name="姓名" size="17" style="color: #000000; font-size: 10pt"></td>
<td align="right" width="15%" height="35"> <p align="left">
<font size="2">聯絡電話：</font></td>
<td width="34%" height="35"> <input type="text" name="聯絡電話" size="21" style="color: #000000; font-size: 10pt"></td>
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<td width="16%" align="right" height="26"> <font size="2">已
持 有：</font></td>
<td width="84%" height="26" colspan="3"> <font size="2">
<input type="checkbox" name="C1" value="台新卡">
台新卡
<input type="checkbox" name="C2" value="渣打卡">
渣打卡
<input type="checkbox" name="C3" value="花旗卡">
花旗卡
<input type="checkbox" name="C4" value="其他">
其他</font></td>
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<td width="16%" align="right"> <font size="2">我要申辦：</font></td>
<td colspan="3"> <font size="2">
<input type="checkbox" name="d1" value="小額現金貸款方案">
</font> <font style="font-size: 9pt">
小額現金貸款方案</font><font size="2">
<input type="checkbox" name="d2" value="信用卡、現金卡餘額代償方案">
</font><font style="font-size: 9pt">信用卡、現金卡餘額代償方案</font><font size="2">
<input type="checkbox" name="d3" value="兩者皆要">
</font><font style="font-size: 9pt">
兩者皆要</font></td>
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<td width="16%" align="right"><font size="2">聯絡地址：</font></td>
<td colspan="3"> <input type="text" name="聯絡地址" size="51" style="color: #000000; font-size: 10pt"></td>
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<td width="16%" align="right"><font size="2">備 註：</font></td>
<td colspan="3"> <textarea rows="4" name="備註" cols="50" style="color: #000000; font-size: 10pt"></textarea></td>
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</table></td>
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</table>
</div></td>
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<td height="19">
<p align="center"><input type="submit" value="確定並送出" name="B1"></td>
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</table></div>
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