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Chakmak
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<td><p>Follow us on: </p></td>
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<form id="emf-form" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/20oa5BfPJ4l7di61bZDv" name="emf-form">
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<td style="" colspan="2">
<font face="Verdana" size="2" color="#000000"><b style="font-size:20px;">Contribute</b><br />
<label style="font-size:15px;">Please fill this short form.Our representative will get back to you within 24 working hours<br /></label><br /></font>
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<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Name</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<table cellpadding='0' cellspacing='0' border='0'>
<tr>
<td align='center' style='padding-left:0;padding-right:3px;'>
<input style='width:60px;' value='' id='element_0_2' name='element_0[]' type='text' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">First</font>
</td>
<td align='center' style='padding-left:0;'>
<input style='width:100px;' value='' id='element_0_3' name='element_0[]' type='text' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">Last</font>
</td>
</tr>
</table>
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Email</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<input id="element_1" name="element_1" class="validate[required,custom[email]]" value="" size="30" type="text" />
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Address</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<table cellpadding='0' cellspacing='0' border='0' width='100%'>
<tr>
<td colspan='2' style='padding-left:0;'>
<input value='' type='text' style='width:99%;' id='element_2_1' name='element_2[]' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">Street Address</font>
</td>
</tr>
<tr>
<td colspan='2' style='padding-left:0;'>
<input value='' type='text' style='width:99%;' id='element_2_2' name='element_2[]' class='validate[optional]' /><br />
<font face="Verdana" size="2" color="#000000">Address Line 2</font>
</td>
</tr>
<tr>
<td style='width:50%;padding-left:0;'>
<input value='' type='text' style='width:99%;' id='element_2_3' name='element_2[]' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">City</font>
</td>
<td style='width:50%;padding-left:5px;'>
<input value='' type='text' style='width:99%;' id='element_2_4' name='element_2[]' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">State / Province / Region</font>
</td>
</tr>
<tr>
<td style='width:50%;padding-left:0;'>
<input value='' type='text' style='width:99%;' id='element_2_5' name='element_2[]' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">Postal / Zip Code</font>
</td>
<td style='width:50%;padding-left:5px;'>
<select style='width:100%;' id='element_2_6' name='element_2[]' class='validate[required]'>
<optgroup label="North America">
<option value="Antigua and Barbuda">
Antigua and Barbuda
</option>
<option value="Aruba,Bahamas">
Aruba,Bahamas
</option>
<option value="Barbados">
Barbados
</option>
<option value="Belize">
Belize
</option>
<option value="Canada">
Canada
</option>
<option value="Cook Islands">
Cook Islands
</option>
<option value="Costa Rica">
Costa Rica
</option>
<option value="Cuba">
Cuba
</option>
<option value="Dominica">
Dominica
</option>
<option value="Dominican Republic">
Dominican Republic
</option>
<option value="El Salvador">
El Salvador
</option>
<option value="Grenada">
Grenada
</option>
<option value="Guatemala">
Guatemala
</option>
<option value="Haiti">
Haiti
</option>
<option value="Honduras">
Honduras
</option>
<option value="Jamaica">
Jamaica
</option>
<option value="Mexico">
Mexico
</option>
<option value="Netherlands Antilles">
Netherlands Antilles
</option>
<option value="Nicaragua">
Nicaragua
</option>
<option value="Panama ">
Panama
</option>
<option value="Puerto Rico ">
Puerto Rico
</option>
<option value="Saint Kitts and Nevis">
Saint Kitts and Nevis
</option>
<option value="Saint Lucia">
Saint Lucia
</option>
<option value="Saint Vincent and the Grenadines">
Saint Vincent and the Grenadines
</option>
<option value="Trinidad and Tobago">
Trinidad and Tobago
</option>
<option value="United States">
United States
</option>
</optgroup>
<optgroup label="South America">
<option value="Argentina">
Argentina
</option>
<option value="Bolivia">
Bolivia
</option>
<option value="Brazil">
Brazil
</option>
<option value="Chile">
Chile
</option>
<option value="Colombia">
Colombia
</option>
<option value="Ecuador">
Ecuador
</option>
<option value="Guyana">
Guyana
</option>
<option value="Paraguay">
Paraguay
</option>
<option value="Peru">
Peru
</option>
<option value="Suriname">
Suriname
</option>
<option value="Uruguay">
Uruguay
</option>
<option value="Venezuela">
Venezuela
</option>
</optgroup>
<optgroup label="Europe">
<option value="Albania">
Albania
</option>
<option value="Andorra">
Andorra
</option>
<option value="Armenia">
Armenia
</option>
<option value="Austria">
Austria
</option>
<option value="Azerbaijan">
Azerbaijan
</option>
<option value="Belarus">
Belarus
</option>
<option value="Belgium">
Belgium
</option>
<option value="Bosnia and Herzegovina">
Bosnia and Herzegovina
</option>
<option value="Bulgaria">
Bulgaria
</option>
<option value="Croatia">
Croatia
</option>
<option value="Cyprus">
Cyprus
</option>
<option value="Czech Republic">
Czech Republic
</option>
<option value="Denmark">
Denmark
</option>
<option value="Estonia">
Estonia
</option>
<option value="Faroe Islands">
Faroe Islands
</option>
<option value="Finland">
Finland
</option>
<option value="France">
France
</option>
<option value="Georgia">
Georgia
</option>
<option value="Germany">
Germany
</option>
<option value="Greece">
Greece
</option>
<option value="Hungary">
Hungary
</option>
<option value="Iceland">
Iceland
</option>
<option value="Ireland">
Ireland
</option>
<option value="Italy">
Italy
</option>
<option value="Latvia">
Latvia
</option>
<option value="Liechtenstein">
Liechtenstein
</option>
<option value="Lithuania">
Lithuania
</option>
<option value="Luxembourg">
Luxembourg
</option>
<option value="Macedonia">
Macedonia
</option>
<option value="Malta">
Malta
</option>
<option value="Moldova">
Moldova
</option>
<option value="Monaco">
Monaco
</option>
<option value="Montenegro">
Montenegro
</option>
<option value="Netherlands">
Netherlands
</option>
<option value="Norway">
Norway
</option>
<option value="Poland">
Poland
</option>
<option value="Portugal">
Portugal
</option>
<option value="Romania">
Romania
</option>
<option value="San Marino">
San Marino
</option>
<option value="Serbia">
Serbia
</option>
<option value="Slovakia">
Slovakia
</option>
<option value="Slovenia">
Slovenia
</option>
<option value="Spain">
Spain
</option>
<option value="Sweden">
Sweden
</option>
<option value="Switzerland">
Switzerland
</option>
<option value="Ukraine">
Ukraine
</option>
<option value="United Kingdom">
United Kingdom
</option>
<option value="Vatican City">
Vatican City
</option>
</optgroup>
<optgroup label="Asia">
<option value="Afghanistan">
Afghanistan
</option>
<option value="Bahrain">
Bahrain
</option>
<option value="Bangladesh">
Bangladesh
</option>
<option value="Bhutan">
Bhutan
</option>
<option value="Brunei Darussalam">
Brunei Darussalam
</option>
<option value="Myanmar">
Myanmar
</option>
<option value="Cambodia">
Cambodia
</option>
<option value="China">
China
</option>
<option value="East Timor">
East Timor
</option>
<option value="Hong Kong">
Hong Kong
</option>
<option value="India" selected="selected">
India
</option>
<option value="Indonesia">
Indonesia
</option>
<option value="Iran">
Iran
</option>
<option value="Iraq">
Iraq
</option>
<option value="Israel">
Israel
</option>
<option value="Japan">
Japan
</option>
<option value="Jordan">
Jordan
</option>
<option value="Kazakhstan">
Kazakhstan
</option>
<option value="North Korea">
North Korea
</option>
<option value="South Korea">
South Korea
</option>
<option value="Kuwait">
Kuwait
</option>
<option value="Kyrgyzstan">
Kyrgyzstan
</option>
<option value="Laos">
Laos
</option>
<option value="Lebanon">
Lebanon
</option>
<option value="Malaysia">
Malaysia
</option>
<option value="Maldives">
Maldives
</option>
<option value="Mongolia">
Mongolia
</option>
<option value="Nepal">
Nepal
</option>
<option value="Oman">
Oman
</option>
<option value="Pakistan">
Pakistan
</option>
<option value="Palestine">
Palestine
</option>
<option value="Philippines">
Philippines
</option>
<option value="Qatar">
Qatar
</option>
<option value="Russia">
Russia
</option>
<option value="Saudi Arabia">
Saudi Arabia
</option>
<option value="Singapore">
Singapore
</option>
<option value="Sri Lanka">
Sri Lanka
</option>
<option value="Syria">
Syria
</option>
<option value="Taiwan">
Taiwan
</option>
<option value="Tajikistan">
Tajikistan
</option>
<option value="Thailand">
Thailand
</option>
<option value="Turkey">
Turkey
</option>
<option value="Turkmenistan">
Turkmenistan
</option>
<option value="United Arab Emirates">
United Arab Emirates
</option>
<option value="Uzbekistan">
Uzbekistan
</option>
<option value="Vietnam">
Vietnam
</option>
<option value="Yemen">
Yemen
</option>
</optgroup>
<optgroup label="Oceania">
<option value="Australia">
Australia
</option>
<option value="Fiji">
Fiji
</option>
<option value="Kiribati">
Kiribati
</option>
<option value="Marshall Islands">
Marshall Islands
</option>
<option value="Micronesia">
Micronesia
</option>
<option value="Nauru">
Nauru
</option>
<option value="New Zealand">
New Zealand
</option>
<option value="Palau">
Palau
</option>
<option value="Papua New Guinea">
Papua New Guinea
</option>
<option value="Samoa">
Samoa
</option>
<option value="Solomon Islands">
Solomon Islands
</option>
<option value="Tonga">
Tonga
</option>
<option value="Tuvalu">
Tuvalu
</option>
<option value="Vanuatu">
Vanuatu
</option>
</optgroup>
<optgroup label="Africa">
<option value="Algeria">
Algeria
</option>
<option value="Angola">
Angola
</option>
<option value="Benin">
Benin
</option>
<option value="Botswana">
Botswana
</option>
<option value="Burkina Faso">
Burkina Faso
</option>
<option value="Burundi">
Burundi
</option>
<option value="Cameroon">
Cameroon
</option>
<option value="Cape Verde">
Cape Verde
</option>
<option value="Central African Republic">
Central African Republic
</option>
<option value="Chad">
Chad
</option>
<option value="Comoros">
Comoros
</option>
<option value="Democratic Republic of the Congo">
Democratic Republic of the Congo
</option>
<option value="Republic of the Congo">
Republic of the Congo
</option>
<option value="Djibouti">
Djibouti
</option>
<option value="Egypt">
Egypt
</option>
<option value="Equatorial Guinea">
Equatorial Guinea
</option>
<option value="Eritrea">
Eritrea
</option>
<option value="Ethiopia">
Ethiopia
</option>
<option value="Gabon">
Gabon
</option>
<option value="Gambia">
Gambia
</option>
<option value="Ghana">
Ghana
</option>
<option value="Gibraltar">
Gibraltar
</option>
<option value="Guinea">
Guinea
</option>
<option value="Guinea-Bissau">
Guinea-Bissau
</option>
<option value="Cote d'Ivoire">
Cote d'Ivoire
</option>
<option value="Kenya">
Kenya
</option>
<option value="Lesotho">
Lesotho
</option>
<option value="Liberia">
Liberia
</option>
<option value="Libya">
Libya
</option>
<option value="Madagascar">
Madagascar
</option>
<option value="Malawi">
Malawi
</option>
<option value="Mali">
Mali
</option>
<option value="Mauritania">
Mauritania
</option>
<option value="Mauritius">
Mauritius
</option>
<option value="Morocco">
Morocco
</option>
<option value="Mozambique">
Mozambique
</option>
<option value="Namibia">
Namibia
</option>
<option value="Niger">
Niger
</option>
<option value="Nigeria">
Nigeria
</option>
<option value="Rwanda">
Rwanda
</option>
<option value="Sao Tome and Principe">
Sao Tome and Principe
</option>
<option value="Senegal">
Senegal
</option>
<option value="Seychelles">
Seychelles
</option>
<option value="Sierra Leone">
Sierra Leone
</option>
<option value="Somalia">
Somalia
</option>
<option value="South Africa">
South Africa
</option>
<option value="Sudan">
Sudan
</option>
<option value="Swaziland">
Swaziland
</option>
<option value="United Republic of Tanzania">
United Republic of Tanzania
</option>
<option value="Togo">
Togo
</option>
<option value="Tunisia">
Tunisia
</option>
<option value="Uganda">
Uganda
</option>
<option value="Zambia">
Zambia
</option>
<option value="Zimbabwe">
Zimbabwe
</option>
</optgroup>
</select><br />
<font face="Verdana" size="2" color="#000000">Country</font>
</td>
</tr>
</table>
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>I'll contribute</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<div style="float:left;width:50%;padding-bottom:5px;">
<input id="element_3_0" name="element_3" value="Story" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000"> Story </font>
</div>
<div style="float:left;width:50%;padding-bottom:5px;">
<input id="element_3_1" name="element_3" value="Poem" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000"> Poem </font>
</div>
<div style="float:left;width:50%;padding-bottom:5px;">
<input id="element_3_2" name="element_3" value="Drawing/Illustration/Image" class="validate[required]" type="radio" /><font face="Verdana" size="2" color=
"#000000"> Drawing/Illustration/Image </font>
</div>
<div style="float:left;width:50%;padding-bottom:5px;">
<input id="element_3_3" name="element_3" value="Other" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000"> Other </font>
</div>
<div style="clear:both;"></div>
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Number</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<input id="element_4" name="element_4" class="validate[required,custom[onlyNumber]]" value="" size="30" type="text" />
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr>
<td colspan="2">
<table cellpadding="5" cellspacing="0" bgcolor="#E4F8E4" width="100%">
<tr bgcolor="#AAD6AA">
<td colspan="2">
<font color="#FFFFFF" face="Verdana" size="2"><b>Image Verification</b></font>
</td>
</tr>
<tr>
<td style="padding:2px; width:100px;">
<img id="captcha_image" src="http://www.emailmeform.com/builder/captcha/index/e6c1e3a234cbb5e81e1bf1368dfd619a" alt="captcha" name="captcha_image" />
</td>
<td valign="top">
<div>
<font color="#000000">Please enter the text from the image</font>:<br />
<input type="text" id="captcha_code" name="captcha_code" maxlength="10" size="10" class="validate[required,funcCall[valid_captcha]]" /> [<a id="captcha_code_refresh" href=
"javascript:void(0);" onclick="document.getElementById('captcha_image').src = 'http://www.emailmeform.com/builder/captcha/index/'+Math.random();get_valid_captcha();return false;"
name="captcha_code_refresh">Refresh Image</a>] [<a id="captcha_code_about" href="javascript:void(0);" onclick=
"window.open('http://www.emailmeform.com/captcha-instruction.html','_blank','width=400, height=500, left=' + (screen.width-450) + ', top=100');return false;" name=
"captcha_code_about">What's This?</a>]
</div>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<input name="element_counts" value="5" type="hidden" /> <input name="embed" value="forms" type="hidden" /><input value="Submit" type="submit" />
</td>
</tr>
</table>
</form>
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$("#emf-form").validationEngine({
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$("#safari_sessionform").submit();
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</td>
<td>
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<td><a href="subscribe.html"><img src="http://eklavya.in/chakmak/chakmak/images/rate.png" border="1px" /></a></a></td>
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