<TR><TH ALIGN="right">${r}Contact name<BR>(last, first)</TH><TD COLSPAN=3><INPUT TYPE="text" NAME="last" VALUE="$last">, <INPUT TYPE="text" NAME="first" VALUE="$first"></TD><TD ALIGN="right">SS#</TD><TD><INPUT TYPE="text" NAME="ss" VALUE="$ss" SIZE=11></TD></TR>
<TR><TD ALIGN="right">Company</TD><TD COLSPAN=5><INPUT TYPE="text" NAME="company" VALUE="$company" SIZE=70></TD></TR>
<TR><TH ALIGN="right">${r}Address</TH><TD COLSPAN=5><INPUT TYPE="text" NAME="address1" VALUE="$address1" SIZE=70></TD></TR>
<TR><TH ALIGN="right">${r}Contact name<BR>(last, first)</TH><TD COLSPAN=3><INPUT TYPE="text" NAME="last" VALUE="$last">, <INPUT TYPE="text" NAME="first" VALUE="$first"></TD><TD ALIGN="right">SS#</TD><TD><INPUT TYPE="text" NAME="ss" VALUE="$ss" SIZE=11></TD></TR>
<TR><TD ALIGN="right">Company</TD><TD COLSPAN=5><INPUT TYPE="text" NAME="company" VALUE="$company" SIZE=70></TD></TR>
<TR><TH ALIGN="right">${r}Address</TH><TD COLSPAN=5><INPUT TYPE="text" NAME="address1" VALUE="$address1" SIZE=70></TD></TR>