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<table>
<tr>
<td><input type="text" name="firma" size="41" maxlength="50" value="" class="formm">
</tr>
<tr>
<td><input type="text" name="adr" size="41" maxlength="70" class="formm">
</tr>
<tr>
<td><input type="text" name="adr1" size="41" maxlength="70" class="formm">
</tr>
<tr>
<td><input type="text" name="tel" size="15" maxlength="15" value="" class="formm">
</tr>
<tr>
<td><input type="text" name="tel1" size="15" maxlength="15" value="" class="formm">
</tr>
<tr>
<td><input type="text" name="em" size="41" maxlength="50" class="formm">
</tr>
</table>
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