<div id="requestvarnumber">

<p>Fill in the fields below to obtain a VAR number to get discount pricing, specials, and unique access to the Envoy Data E-Commerce Store.</p>

<table cellspacing="5" cellpadding="4" border="0" class="requestvarnumber" style="width: 653px; height: 377px;">
    <tbody>
        <tr>
            <td width="90" nowrap="nowrap"><label for="FirstName">First Name:</label></td>
            <td width="642"><input type="text" name="1. FirstName" id="FirstName" tabindex="1" />&nbsp;</td>
        </tr>
        <tr>
            <td><label for="LastName">Last Name:</label></td>
            <td><input type="text" name="2. LastName" id="LastName" tabindex="2" />&nbsp;</td>
        </tr>
        <tr>
            <td nowrap="nowrap"><label for="Company">Company Name:</label></td>
            <td><input type="text" name="5. Company Name:" id="Company" tabindex="3" />&nbsp;</td>
        </tr>
        <tr>
            <td nowrap="nowrap"><label for="Phone">Phone Number:</label></td>
            <td><input type="text" name="5. Phone Number" id="Phone" tabindex="4" />&nbsp;</td>
        </tr>
        <tr>
            <td><label for="Email">Email:</label></td>
            <td><input type="text" name="3. Email" id="Email" tabindex="5" />&nbsp;</td>
        </tr>
        <tr>
            <td valign="top"><label for="ConfirmEmail">Confirm Email:</label></td>
            <td valign="top"><input type="text" name="ConfirmEmail" id="ConfirmEmail2" tabindex="6" /></td>
        </tr>
        <tr>
        </tr>
        <tr>
        </tr>
        <tr>
            <td valign="top" colspan="2" style="color: rgb(102, 102, 102); font-size: 13px;"><strong><input type="checkbox" value="" name="Opt-in" /> Would you like receive updates about promotions, discounts, and other valuable information about Envoy Data and our products?</strong></td>
        </tr>
        <tr>
            <td valign="top" colspan="2" style="color: rgb(102, 102, 102); font-size: 13px;"><strong><input type="checkbox" value="" name="Opt-in" /> Would you like receive be added to our E-mail Marketing List to receive newsletters, e-mail blasts, and other marketing distribution?<br />
            <br />
            </strong></td>
        </tr>
        <tr>
            <td colspan="2"><input type="submit" button="" value="submit" tabindex="8" /></td>
        </tr>
    </tbody>
</table>
</div>
<p>&nbsp;</p>