<div align="center"><span style="font-size: 24pt;"><b> <span style="color: rgb(255, 20, 147); font-size: 24pt;">общие данные</span></b></span></div>
<table id="table1" width="100%" border="0" cellpadding="2" cellspacing="1">
<tbody><tr><td width="35%">Фамилия <span style="color: red;">*</span>:</td><td><input name="f2" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>имя <span style="color: red;">*</span>:</td><td><input name="f25" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>Отчество <span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>E-mail отправителя <span style="color: red;">*</span>:</td><td><input name="f1" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>дата рождения <span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr></tbody></table>

<div align="center"><span style="font-size: 24pt;"><b> <span style="color: rgb(255, 20, 147); font-size: 24pt;">паспорт</span></b></span></div>
<table id="table1" width="100%" border="0" cellpadding="2" cellspacing="1">
<tbody><tr><td width="35%">серия <span style="color: red;">*</span>:</td><td><input name="f2" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>номер<span style="color: red;">*</span>:</td><td><input name="f25" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>код подразделения<span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>дата выдачи<span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>кем выдан<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr></tbody></table>

<div align="center"><span style="font-size: 24pt;"><b> <span style="color: rgb(255, 20, 147); font-size: 24pt;"> адрес постоянного проживания</span></b></span></div>
<table id="table1" width="100%" border="0" cellpadding="2" cellspacing="1">
<tbody><tr><td width="35%">индекс<span style="color: red;">*</span>:</td><td><input name="f2" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>область<span style="color: red;">*</span>:</td><td><input name="f25" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>населенный пункт<span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>улица<span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>дом<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>корпус(при отсутствии укажите нет)<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>квартира(при отсутствии укажите нет)<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
</tbody></table>

<div align="center"><span style="font-size: 24pt;"><b> <span style="color: rgb(255, 20, 147); font-size: 24pt;">адрес регистрации</span></b></span></div>
<table id="table1" width="100%" border="0" cellpadding="2" cellspacing="1">
<tbody>
<tr><td width="35%">индекс<span style="color: red;">*</span>:</td><td><input name="f2" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>область<span style="color: red;">*</span>:</td><td><input name="f25" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>населенный пункт<span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>улица<span style="color: red;">*</span>:</td><td><input name="f4" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>дом<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>корпус(при отсутствии укажите нет)<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>квартира(при отсутствии укажите нет)<span style="color: red;">*</span>:</td><td><input name="f5" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
</tbody></table>

<div align="center"><span style="font-size: 24pt;"><b> <span style="color: rgb(255, 20, 147); font-size: 24pt;">телефоны</span></b></span></div>
<table id="table1" width="100%" border="0" cellpadding="2" cellspacing="1">
<tbody>
<tr><td width="35%">мобильный<span style="color: red;">*</span>:</td><td><input name="f2" size="30" style="width:95%;" maxlength="70" type="text"> </td></tr>
<tr><td>домашний:</td><td><input type="text" name="f20" size="30" style="width:95%;" maxlength="70"> </td></tr>
<tr><td>работаете или работали ранее представителем/партнером? <font color="red">*</font>:</td><td><input id="fr211" type="radio" name="f21" value="работаю"> <label for="fr211">работаю</label><br /><input id="fr212" type="radio" name="f21" value="работал(а)"> <label for="fr212">работал(а)</label><br /><input id="fr213" type="radio" name="f21" value="не работал"> <label for="fr213">не работал</label><br /></td></tr>
<tr><td>примечание:</td><td><textarea rows="7" name="f22" cols="30" style="width:95%;"></textarea> </td></tr>
<tr><td>Обработка первональных данных <font color="red">*</font>:</td><td><select size="1" name="f23"><option>согласна</option> <option>не согласна</option></select></td></tr>
<tr><td>введите цифры <font color="red">*</font>:</td><td><input type="text" name="f26" size="6" maxlength="5"> $SECURITY_CODE$</td></tr>
<tr><td colspan="2" align="center"><br /><input type="submit" value="Отправить сообщение"></td></tr>
</tbody></table>