Unfortunately, I don't know where the problem would be... since I created this through the wizard.
<%
' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit.
On Error Resume Next
Session("FP_OldCodePage"

= Session.CodePage
Session("FP_OldLCID"

= Session.LCID
Session.CodePage = 1252
Session.LCID = 1033
Err.Clear
strErrorUrl = ""
If Request.ServerVariables("REQUEST_METHOD"

= "POST" Then
If Request.Form("VTI-GROUP"

= "0" Then
Err.Clear
Set fp_conn = Server.CreateObject("ADODB.Connection"

FP_DumpError strErrorUrl, "Cannot create connection"
Set fp_rs = Server.CreateObject("ADODB.Recordset"

FP_DumpError strErrorUrl, "Cannot create record set"
fp_conn.Open Application("automaxxconnect_ConnectionString"

FP_DumpError strErrorUrl, "Cannot open database"
fp_rs.Open "Customers", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable
FP_DumpError strErrorUrl, "Cannot open record set"
fp_rs.AddNew
FP_DumpError strErrorUrl, "Cannot add new record set to the database"
Dim arFormFields0(53)
Dim arFormDBFields0(53)
Dim arFormValues0(53)
arFormFields0(0) = "DriversLicenseState"
arFormDBFields0(0) = "DriversLicenseState"
arFormValues0(0) = Request("DriversLicenseState"

arFormFields0(1) = "PreviousPayment"
arFormDBFields0(1) = "PreviousPayment"
arFormValues0(1) = Request("PreviousPayment"

arFormFields0(2) = "Bankruptcy"
arFormDBFields0(2) = "Bankruptcy"
arFormValues0(2) = Request("Bankruptcy"

arFormFields0(3) = "PreviousState"
arFormDBFields0(3) = "PreviousState"
arFormValues0(3) = Request("PreviousState"

arFormFields0(4) = "PreviousEmployerPhone"
arFormDBFields0(4) = "PreviousEmployerPhone"
arFormValues0(4) = Request("PreviousEmployerPhone"

arFormFields0(5) = "DriversLicenseNumber"
arFormDBFields0(5) = "DriversLicenseNumber"
arFormValues0(5) = Request("DriversLicenseNumber"

arFormFields0(6) = "CurrentCity"
arFormDBFields0(6) = "CurrentCity"
arFormValues0(6) = Request("CurrentCity"

arFormFields0(7) = "CellPhone"
arFormDBFields0(7) = "CellPhone"
arFormValues0(7) = Request("CellPhone"

arFormFields0(8) = "CoBuyerCurrentEmployer"
arFormDBFields0(8) = "CoBuyerCurrentEmployer"
arFormValues0(8) = Request("CoBuyerCurrentEmployer"

arFormFields0(9) = "CoBuyerCurrentGrossMonthlyIncome"
arFormDBFields0(9) = "CoBuyerCurrentGrossMonthlyIncome"
arFormValues0(9) = Request("CoBuyerCurrentGrossMonthlyIncome"

arFormFields0(10) = "ExpDate"
arFormDBFields0(10) = "ExpDate"
arFormValues0(10) = Request("ExpDate"

arFormFields0(11) = "HomePhone"
arFormDBFields0(11) = "HomePhone"
arFormValues0(11) = Request("HomePhone"

arFormFields0(12) = "PreviousZipCode"
arFormDBFields0(12) = "PreviousZipCode"
arFormValues0(12) = Request("PreviousZipCode"

arFormFields0(13) = "PrimaryCustomerName"
arFormDBFields0(13) = "PrimaryCustomerName"
arFormValues0(13) = Request("PrimaryCustomerName"

arFormFields0(14) = "DOB"
arFormDBFields0(14) = "DOB"
arFormValues0(14) = Request("DOB"

arFormFields0(15) = "CurrentResidenceLength"
arFormDBFields0(15) = "CurrentResidenceLength"
arFormValues0(15) = Request("CurrentResidenceLength"

arFormFields0(16) = "CoBuyerZipCode"
arFormDBFields0(16) = "CoBuyerZipCode"
arFormValues0(16) = Request("CoBuyerZipCode"

arFormFields0(17) = "CoBuyerCurrentOccupation"
arFormDBFields0(17) = "CoBuyerCurrentOccupation"
arFormValues0(17) = Request("CoBuyerCurrentOccupation"

arFormFields0(18) = "CoBuyerCurrentPositionTime"
arFormDBFields0(18) = "CoBuyerCurrentPositionTime"
arFormValues0(18) = Request("CoBuyerCurrentPositionTime"

arFormFields0(19) = "CurrentEmployerPhone"
arFormDBFields0(19) = "CurrentEmployerPhone"
arFormValues0(19) = Request("CurrentEmployerPhone"

arFormFields0(20) = "CurrentOccupation"
arFormDBFields0(20) = "CurrentOccupation"
arFormValues0(20) = Request("CurrentOccupation"

arFormFields0(21) = "CurrentLandlordPhoneNumber"
arFormDBFields0(21) = "CurrentLandlordPhoneNumber"
arFormValues0(21) = Request("CurrentLandlordPhoneNumber"

arFormFields0(22) = "PreviousAddress1"
arFormDBFields0(22) = "PreviousAddress1"
arFormValues0(22) = Request("PreviousAddress1"

arFormFields0(23) = "CurrentPositionTime"
arFormDBFields0(23) = "CurrentPositionTime"
arFormValues0(23) = Request("CurrentPositionTime"

arFormFields0(24) = "CoBuyerAddress1"
arFormDBFields0(24) = "CoBuyerAddress1"
arFormValues0(24) = Request("CoBuyerAddress1"

arFormFields0(25) = "CoBuyerCity"
arFormDBFields0(25) = "CoBuyerCity"
arFormValues0(25) = Request("CoBuyerCity"

arFormFields0(26) = "CurrentState1"
arFormDBFields0(26) = "CurrentState1"
arFormValues0(26) = Request("CurrentState1"

arFormFields0(27) = "PreviousAddress2"
arFormDBFields0(27) = "PreviousAddress2"
arFormValues0(27) = Request("PreviousAddress2"

arFormFields0(28) = "PreviousResidenceLength"
arFormDBFields0(28) = "PreviousResidenceLength"
arFormValues0(28) = Request("PreviousResidenceLength"

arFormFields0(29) = "PreviousEmployerName"
arFormDBFields0(29) = "PreviousEmployerName"
arFormValues0(29) = Request("PreviousEmployerName"

arFormFields0(30) = "OtherIncomeType"
arFormDBFields0(30) = "OtherIncomeType"
arFormValues0(30) = Request("OtherIncomeType"

arFormFields0(31) = "CoBuyerAddress2"
arFormDBFields0(31) = "CoBuyerAddress2"
arFormValues0(31) = Request("CoBuyerAddress2"

arFormFields0(32) = "PreviousResidentialType"
arFormDBFields0(32) = "PreviousResidentialType"
arFormValues0(32) = Request("PreviousResidentialType"

arFormFields0(33) = "SSN"
arFormDBFields0(33) = "SSN"
arFormValues0(33) = Request("SSN"

arFormFields0(34) = "CurrentAddress1"
arFormDBFields0(34) = "CurrentAddress1"
arFormValues0(34) = Request("CurrentAddress1"

arFormFields0(35) = "Repossession"
arFormDBFields0(35) = "Repossession"
arFormValues0(35) = Request("Repossession"

arFormFields0(36) = "CurrentAddress2"
arFormDBFields0(36) = "CurrentAddress2"
arFormValues0(36) = Request("CurrentAddress2"

arFormFields0(37) = "CurrentPayment"
arFormDBFields0(37) = "CurrentPayment"
arFormValues0(37) = Request("CurrentPayment"

arFormFields0(38) = "PreviousCity"
arFormDBFields0(38) = "PreviousCity"
arFormValues0(38) = Request("PreviousCity"

arFormFields0(39) = "CurrentGrossSalary"
arFormDBFields0(39) = "CurrentGrossSalary"
arFormValues0(39) = Request("CurrentGrossSalary"

arFormFields0(40) = "CoBuyerCurrentEmployerPhone"
arFormDBFields0(40) = "CoBuyerCurrentEmployerPhone"
arFormValues0(40) = Request("CoBuyerCurrentEmployerPhone"

arFormFields0(41) = "CurrentEmployer"
arFormDBFields0(41) = "CurrentEmployer"
arFormValues0(41) = Request("CurrentEmployer"

arFormFields0(42) = "OtherIncomeAmount"
arFormDBFields0(42) = "OtherIncomeAmount"
arFormValues0(42) = Request("OtherIncomeAmount"

arFormFields0(43) = "CoBuyerCustomerName"
arFormDBFields0(43) = "CoBuyerCustomerName"
arFormValues0(43) = Request("CoBuyerCustomerName"

arFormFields0(44) = "PreviousPositionTime"
arFormDBFields0(44) = "PreviousPositionTime"
arFormValues0(44) = Request("PreviousPositionTime"

arFormFields0(45) = "CoBuyerDOB"
arFormDBFields0(45) = "CoBuyerDOB"
arFormValues0(45) = Request("CoBuyerDOB"

arFormFields0(46) = "CurrentZipCode"
arFormDBFields0(46) = "CurrentZipCode"
arFormValues0(46) = Request("CurrentZipCode"

arFormFields0(47) = "CurrentLandlordName"
arFormDBFields0(47) = "CurrentLandlordName"
arFormValues0(47) = Request("CurrentLandlordName"

arFormFields0(48) = "PreviousOccupation"
arFormDBFields0(48) = "PreviousOccupation"
arFormValues0(48) = Request("PreviousOccupation"

arFormFields0(49) = "CurrentState"
arFormDBFields0(49) = "CurrentState"
arFormValues0(49) = Request("CurrentState"

arFormFields0(50) = "T1"
arFormDBFields0(50) = "T1"
arFormValues0(50) = Request("T1"

arFormFields0(51) = "WorkPhone"
arFormDBFields0(51) = "WorkPhone"
arFormValues0(51) = Request("WorkPhone"

arFormFields0(52) = "CoBuyerRelationship"
arFormDBFields0(52) = "CoBuyerRelationship"
arFormValues0(52) = Request("CoBuyerRelationship"
FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0
If Request.ServerVariables("REMOTE_HOST"

<> "" Then
FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"

, "Remote_computer_name"
End If
If Request.ServerVariables("HTTP_USER_AGENT"

<> "" Then
FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"

, "Browser_type"
End If
FP_SaveFieldToDB fp_rs, Now, "Timestamp"
If Request.ServerVariables("REMOTE_USER"

<> "" Then
FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"

, "User_name"
End If
fp_rs.Update
FP_DumpError strErrorUrl, "Cannot update the database"
fp_rs.Close
fp_conn.Close
FP_FormConfirmation "text/html; charset=windows-1252",_
"Form Confirmation",_
"Thank you for submitting the following information:",_
"creditapp.asp",_
"Return to the form."
End If
End If
Session.CodePage = Session("FP_OldCodePage"

Session.LCID = Session("FP_OldLCID"
%>
<HTML>
<HEAD>
<meta HTTP-EQUIV="Content-Type" CONTENT="text/html; charset=windows-1252">
<meta http-equiv="Content-Language" content="en-us">
<TITLE>creditapplication</TITLE>
</HEAD>
<BODY>
<H1>Credit Application <img border="0" src="approved.gif"></H1>
<HR>
<P>
AutoMaxx Motors will get you financed! Whether you have perfect credit,
bad credit or no credit, we work with several lenders making it easy for you to
drive home in your perfect vehicle today!</P>
<FORM METHOD="POST" ACTION="--WEBBOT-SELF--">
<!--webbot bot="SaveDatabase" suggestedext="asp" u-asp-include-url="_fpclass/fpdbform.inc" s-dataconnection="automaxxconnect" s-recordsource="Customers" u-database-url="automaxxwebdb.mdb" s-builtin-fields="REMOTE_HOST HTTP_USER_AGENT Timestamp REMOTE_USER" s-builtin-dbfields="Remote_computer_name Browser_type Timestamp User_name" s-form-fields="DriversLicenseState PreviousPayment Bankruptcy PreviousState PreviousEmployerPhone DriversLicenseNumber CurrentCity CellPhone CoBuyerCurrentEmployer CoBuyerCurrentGrossMonthlyIncome ExpDate HomePhone PreviousZipCode PrimaryCustomerName DOB CurrentResidenceLength CoBuyerZipCode CoBuyerCurrentOccupation CoBuyerCurrentPositionTime CurrentEmployerPhone CurrentOccupation CurrentLandlordPhoneNumber PreviousAddress1 CurrentPositionTime CoBuyerAddress1 CoBuyerCity CurrentState1 PreviousAddress2 PreviousResidenceLength PreviousEmployerName OtherIncomeType CoBuyerAddress2 PreviousResidentialType SSN CurrentAddress1 Repossession CurrentAddress2 CurrentPayment PreviousCity CurrentGrossSalary CoBuyerCurrentEmployerPhone CurrentEmployer OtherIncomeAmount CoBuyerCustomerName PreviousPositionTime CoBuyerDOB CurrentZipCode CurrentLandlordName PreviousOccupation CurrentState T1 WorkPhone CoBuyerRelationship" s-form-dbfields="DriversLicenseState PreviousPayment Bankruptcy PreviousState PreviousEmployerPhone DriversLicenseNumber CurrentCity CellPhone CoBuyerCurrentEmployer CoBuyerCurrentGrossMonthlyIncome ExpDate HomePhone PreviousZipCode PrimaryCustomerName DOB CurrentResidenceLength CoBuyerZipCode CoBuyerCurrentOccupation CoBuyerCurrentPositionTime CurrentEmployerPhone CurrentOccupation CurrentLandlordPhoneNumber PreviousAddress1 CurrentPositionTime CoBuyerAddress1 CoBuyerCity CurrentState1 PreviousAddress2 PreviousResidenceLength PreviousEmployerName OtherIncomeType CoBuyerAddress2 PreviousResidentialType SSN CurrentAddress1 Repossession CurrentAddress2 CurrentPayment PreviousCity CurrentGrossSalary CoBuyerCurrentEmployerPhone CurrentEmployer OtherIncomeAmount CoBuyerCustomerName PreviousPositionTime CoBuyerDOB CurrentZipCode CurrentLandlordName PreviousOccupation CurrentState T1 WorkPhone CoBuyerRelationship" startspan --><input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--#include file="_fpclass/fpdbform.inc"--><!--webbot bot="SaveDatabase" endspan i-checksum="40548" --><P>
</P>
<BLOCKQUOTE>
<TABLE width="747" height="20" style="border-collapse: collapse" bordercolor="#111111" cellpadding="0" cellspacing="0">
<TR>
<TD ALIGN="right" width="140" height="14">
</TD>
<TD bgcolor="#BFEB94" width="597" height="14">
<p align="center">Please provide your <b>personal</b> information:
</TR>
<TR>
<TD ALIGN="right" width="140" height="10" valign="top">
</TD>
<TD width="597" height="10" valign="top">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="10" valign="top">
</TD>
<TD width="597" height="10" valign="top">
<i>Primary Applicant Name:</i>
<INPUT NAME="PrimaryCustomerName" SIZE=20 tabindex="1"> </TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="10" valign="top">
</TD>
<TD width="597" height="10" valign="top">
<i>Birthdate: </i>
<input type="text" name="DOB" size="20" tabindex="2"> <i>Social
Security #: </i>
<input type="text" name="SSN" size="20" tabindex="3"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="10" valign="top">
</TD>
<TD width="597" height="10" valign="top">
<i>Drivers License
State: </i>
<input type="text" name="DriversLicenseState" size="3" value="=PA">
<i> Number: </i> <input type="text" name="DriversLicenseNumber" size="10" tabindex="4">
<i>Expiration Date: </i> <input type="text" name="ExpDate" size="10" tabindex="5"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="10" valign="top">
</TD>
<TD width="597" height="10" valign="top">
<i>Have you ever had any repossessions </i>
<input type="checkbox" name="Repossession" value="ON" tabindex="9">
<i>or filed for bankruptcy?</i>
<input type="checkbox" name="Bankruptcy" value="ON" tabindex="10"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="15" valign="top">
</TD>
<TD width="597" height="10" valign="top">
</TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD bgcolor="#BFEB94" width="597" height="15">
<p align="center">Please supply your <b>residential</b> information:</TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i>Current Street Address: </i>
<INPUT NAME="CurrentAddress1" SIZE=20 tabindex="11"> </TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i>Address (cont.): </i>
<INPUT NAME="CurrentAddress2" SIZE=20 tabindex="12"> </TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> City, State, Zip Code: </i>
<INPUT NAME="CurrentCity" SIZE=20 tabindex="13">,
<INPUT NAME="CurrentState1" SIZE=5 value="=PA" tabindex="14">
<INPUT NAME="CurrentZipCode" SIZE=10 MAXLENGTH=12 tabindex="15"></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i>Home #: </i> <input type="text" name="HomePhone" size="10" tabindex="6">
<i>Cell #: </i>
<input type="text" name="CellPhone" size="10" tabindex="7"> </TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Residential Status:
<input type="text" name="T1" size="20"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Current Payment:
</i>
<input type="text" name="CurrentPayment" size="20" tabindex="17"></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Time at this residence: </i>
<input type="text" name="CurrentResidenceLength" size="20" tabindex="18"></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i>Current Landlord Name:
<input type="text" name="CurrentLandlordName" size="20" tabindex="19">
Phone #:
<input type="text" name="CurrentLandlordPhoneNumber" size="20" tabindex="20"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i>
----------------------------------------------------------------------------------------------------------------------- </TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Previous Street Address:
<input type="text" name="PreviousAddress1" size="20" tabindex="21"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i>
Address (cont.):
<input type="text" name="PreviousAddress2" size="20" tabindex="22"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> City, State, Zip Code:
<input type="text" name="PreviousCity" size="20" tabindex="23">,
<input type="text" name="PreviousState" size="5" tabindex="24" value="PA">
<input type="text" name="PreviousZipCode" size="10" tabindex="26"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Residential Status:
<select size="1" name="PreviousResidentialType" tabindex="27">
<option>--please select from list--</option>
<option>Rent</option>
<option>Own</option>
<option>Live with family or friends</option>
</select></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Previous Payment:
<input type="text" name="PreviousPayment" size="20" tabindex="28"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
<i> Time at this residence:
<input type="text" name="PreviousResidenceLength" size="20" tabindex="29"></i></TD>
</TR>
<TR>
<TD width="140" height="15">
</TD>
<TD width="597" height="15">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" bgcolor="#BFEB94" height="22">
<p align="center">Please give your <b>employment</b> history:</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Current Employer : </i>
<input type="text" name="CurrentEmployer" size="20" tabindex="30"><i>
Phone #: </i>
<input type="text" name="CurrentEmployerPhone" size="20" tabindex="31"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Current Occupation: </i>
<input type="text" name="CurrentOccupation" size="20" tabindex="32"> <i>
Time in position: </i>
<input type="text" name="CurrentPositionTime" size="20" tabindex="33"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>
Gross Salary: </i>
<input type="text" name="CurrentGrossSalary" size="20" tabindex="35"> <i>
Work Phone #: </i>
<input type="text" name="WorkPhone" size="10" tabindex="8"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
---------------------------------------------------------------------------------------------------</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Previous Employer:
<input type="text" name="PreviousEmployerName" size="20" tabindex="36"> Phone #:
<input type="text" name="PreviousEmployerPhone" size="20" tabindex="37"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Previous Occupation:
<input type="text" name="PreviousOccupation" size="20" tabindex="38"> Time in
position: <input type="text" name="PreviousPositionTime" size="20" tabindex="39"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>If you have another source of income, please specify the type and amount:</i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>Type: <input type="text" name="OtherIncomeType" size="20" tabindex="40">
Amount: <input type="text" name="OtherIncomeAmount" size="20" tabindex="41"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="15">
</TD>
<TD width="597" height="15">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22" bgcolor="#BFEB94">
<p align="center">Please enter <b>co-buyer</b> information.</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>Co-Buyer Name:
<input type="text" name="CoBuyerCustomerName" size="20" tabindex="42">
Birthdate: <input type="text" name="CoBuyerDOB" size="20" tabindex="42"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Street Address:
<input type="text" name="CoBuyerAddress1" size="20" tabindex="43"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Address (cont.):
<input type="text" name="CoBuyerAddress2" size="20" tabindex="44"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> City, State, Zip:
<input type="text" name="CoBuyerCity" size="20" tabindex="45">,
<input type="text" name="CurrentState" size="3" value="=PA" tabindex="46">
<input type="text" name="CoBuyerZipCode" size="10" tabindex="47"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>Current Employer : </i>
<input type="text" name="CoBuyerCurrentEmployer" size="20" tabindex="48"><i>
Phone #: </i>
<input type="text" name="CoBuyerCurrentEmployerPhone" size="20" tabindex="49"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i> Current Occupation: </i>
<input type="text" name="CoBuyerCurrentOccupation" size="20" tabindex="50">
<i>Time in position: </i>
<input type="text" name="CoBuyerCurrentPositionTime" size="20" tabindex="51"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>Gross Salary:
<input type="text" name="CoBuyerCurrentGrossMonthlyIncome" size="20" tabindex="52"></i></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
<i>What is your relationship with this person?</i>
<input type="text" name="CoBuyerRelationship" size="20" tabindex="53"></TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="22">
</TD>
<TD width="597" height="22">
</TD>
</TR>
<TR>
<TD ALIGN="right" width="140" height="19">
</TD>
<TD width="597" height="19">
<hr>
</TD>
</TR>
</TABLE>
</BLOCKQUOTE>
<INPUT TYPE=SUBMIT VALUE="Submit Form">
<INPUT TYPE=RESET VALUE="Reset Form">
</FORM>
<HR>
<H5>
Revised:
<!--WEBBOT BOT=TimeStamp
S-Type="EDITED"
S-Format="%m/%d/%y"
--></H5>
</BODY>
</HTML>