<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="$address1" SIZE=70></TD></TR>
<TR><TD ALIGN="right"> </TD><TD COLSPAN=5><INPUT TYPE="text" NAME="address2" VALUE="$address2" SIZE=70></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="$address1" SIZE=70></TD></TR>
<TR><TD ALIGN="right"> </TD><TD COLSPAN=5><INPUT TYPE="text" NAME="address2" VALUE="$address2" SIZE=70></TD></TR>