<HTML>
  <HEAD>
    <TITLE>*{{title}}*</TITLE>
  </HEAD>
  <BODY>
    <H2>*{{heading}}*</H2>
*{{instructions}}*
    <FORM METHOD="POST" ACTION="*{{action}}*">
	<TABLE WIDTH=50% >
		<COL WIDTH=532>
		<COL WIDTH=541>
			*{{items}}*
	</TABLE>
	 <PRE><FONT SIZE=2>      * Required field</FONT></PRE>
	<PRE>		<INPUT TYPE=SUBMIT VALUE="Send">     <INPUT TYPE=RESET VALUE="Reset"></PRE>

    </FORM>
  </BODY>
</HTML>