<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" style="width: 653px; height: 377px;" class="requestvarnumber">
    <tbody>
        <tr>
            <td width="90" nowrap="nowrap"><label for="FirstName">First Name:</label></td>
            <td width="642"><input type="text" tabindex="1" id="FirstName" name="1. FirstName" />&nbsp;</td>
        </tr>
        <tr>
            <td><label for="LastName">Last Name:</label></td>
            <td><input type="text" tabindex="2" id="LastName" name="2. LastName" />&nbsp;</td>
        </tr>
        <tr>
            <td nowrap="nowrap"><label for="Company">Company Name:</label></td>
            <td><input type="text" tabindex="3" id="Company" name="5. Company Name:" />&nbsp;</td>
        </tr>
        <tr>
            <td nowrap="nowrap"><label for="Phone">Phone Number:</label></td>
            <td><input type="text" tabindex="4" id="Phone" name="5. Phone Number" />&nbsp;</td>
        </tr>
        <tr>
            <td><label for="Email">Email:</label></td>
            <td><input type="text" tabindex="5" id="Email" name="3. Email" />&nbsp;</td>
        </tr>
        <tr>
            <td valign="top"><label for="ConfirmEmail">Confirm Email:</label></td>
            <td valign="top"><input type="text" tabindex="6" id="ConfirmEmail2" name="ConfirmEmail" /></td>
        </tr>
        <tr>
        </tr>
        <tr>
        </tr>
        <tr>
            <td valign="top" style="color: rgb(102, 102, 102); font-size: 13px;" colspan="2"><strong><input type="checkbox" name="Opt-in" value="" /> 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" style="color: rgb(102, 102, 102); font-size: 13px;" colspan="2"><strong><input type="checkbox" name="Opt-in" value="" /> 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" tabindex="8" value="submit" button="" /></td>
        </tr>
    </tbody>
</table>
</div>
<p>&nbsp;</p>