ÿþ<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"> <html> <head> <title>Personnel Touch  Solicite más información</title> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1"> <link href="../link_effects.css" rel="stylesheet" type="text/css"> </head> <body bgcolor="245962"><div align="center"> <p>&nbsp;</p> <table id="Table_01" width="800" height="600" border="0" cellpadding="0" cellspacing="0"> <tr> <td height="67" background="../request_images/request_01.gif"><div align="right"> <table width="80" border="0" cellpadding="2"> <tr> <td valign="bottom"><div align="center"><a href="../request.html"><img src="../flags/flags_US.gif" width="37" height="25"></a></div></td> <td><div align="center"><a href="../it/request.html"><img src="../flags/flags_Italian.gif" width="37" height="25"></a></div></td> </tr> <tr> <td valign="top"><div align="center"><a href="../request.html" class="language">English</a></div></td> <td valign="top"><div align="center"><a href="../it/request.html" class="language">Italiano</a></div></td> </tr> </table> </div></td> </tr> <tr> <td width="800" height="27" background="../request_images/request_02.gif"> <table border="0" width="100%"> <tr valign="top" align="center"> <td><a href="index.html">Página<br />principal</a></td> <td><a href="about.html">Quiénes somos</a></td> <td><a href="international.html">Seguros de<br />cobertura internacional</a></td> <td><a href="domestic.html">Seguros de<br />cobertura nacional</a></td> <td><font color="#FFFFFF">Solicite más<br />información</font></td> <td><a href="links.html">Vínculos</a></td> <td><a href="contact.html">Contacto</a></td> </tr> </table> </td> </tr> <tr> <td width="800" height="506" align="left" valign="top" background="../request_images/request_03.gif"><form action="mailto:info@ptinsurance.biz" method="post" enctype="text/plain" name="Request" target="_blank"> <table width="90%" border="0" align="center"> <tr> <td height="85"> <p><font face="Arial, Helvetica, sans-serif"><br> <font color="#FFFFFF" size="4"><strong>SOLICITUD DE INFORMACIÓN</strong></font><font color="#FFFFFF" size="3"><br> <font size="2">Complete este formulario para que Personnel Touch ponga sus 17 años de experiencia en el sector a su disposición.</font></font></font></p></td> </tr> <tr> <td height="29"> <p><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"><strong>TÍTULO: </strong></font><font color="#FFFFFF"><strong><font size="3" face="Arial, Helvetica, sans-serif"></font></strong></font>&nbsp;&nbsp;&nbsp;<label> <input type="radio" name="Title" value="Mr."> <font color="#FFFFFF"><font size="3" face="Arial, Helvetica, sans-serif">Sr. </font></font></label> <font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"> <label> <input type="radio" name="Title" value="Mrs.">Sra. </label> <label></label> <label></label> <label></label> </font><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"><strong> </strong></font></p></td> </tr> <tr> <td height="33" align="left" valign="middle"> <p><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"><strong>NOMBRE:&nbsp;&nbsp;&nbsp;<input name="Name" type="text" id="Name" size="40"> </strong></font></p></td> </tr> <tr> <td height="34"> <p><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"><strong>NOMBRE DE LA EMPRESA:&nbsp;&nbsp;&nbsp;<input name="Busines Name" type="text" id="Busines Name" size="55"> </strong></font></p></td> </tr> <tr> <td height="34"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">DIRECCIÓN:&nbsp;&nbsp;&nbsp;<input name="Address" type="text" id="Address" size="55"> </font></strong></td> </tr> <tr> <td height="33"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">CIUDAD:&nbsp;&nbsp;&nbsp;<input name="City" type="text" id="City" size="22"> </font></strong></td> </tr> <tr> <td height="34"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">ESTADO / PROVINCIA:&nbsp;&nbsp;&nbsp;<input name="State" type="text" id="State" size="5"> </font></strong></td> </tr> <tr> <td height="34"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">CÓDIGO POSTAL:&nbsp;&nbsp;&nbsp;<input name="Zip Code" type="text" id="Zip Code" size="10"> </font></strong></td> </tr> <tr> <td height="32"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">PAÍS:&nbsp;&nbsp;&nbsp;<input name="Country" type="text" id="Country" size="32"> </font></strong></td> </tr> <tr> <td height="34"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">TELÉFONO:&nbsp;&nbsp;&nbsp;<input name="Telephone" type="text" id="Telephone" size="22"> </font></strong></td> </tr> <tr> <td height="33"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">FAX:&nbsp;&nbsp;&nbsp;<input name="Fax" type="text" id="Fax" size="22"> </font></strong></td> </tr> <tr> <td height="36"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">DIRECCIÓN DE CORREO ELECTRÓNICO:&nbsp;&nbsp;&nbsp;<input name="Email" type="text" id="Email" size="31"> </font></strong></td> </tr> <tr> <td height="33"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">HORARIO DE PREFERENCIA PARA COMUNICARNOS CON USTED:&nbsp;&nbsp;&nbsp;<input name="The Best Time To Contact You" type="text" id="The Best Time To Contact You" size="32"> </font></strong></td> </tr> <tr> <td height="28" align="left" valign="top"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">MOTIVO DE SU CONSULTA:&nbsp;&nbsp;&nbsp; </font></strong> <label> <input type="radio" name="Area of Interest" value="International Insurance"> <font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">Seguros internacionales</font></label> <label> <input type="radio" name="Area of Interest" value="Domestic Insurance"> <font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"> Seguros nacionales </font></label> </td> </tr> <tr> <td height="29" align="left" valign="top"><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif"><strong>¿FUMA USTED?:&nbsp; </strong></font> <label> <input type="radio" name="Are You a Smoker" value="Yes"> <font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">Sí </font></label> <label> <input type="radio" name="Are You a Smoker" value="No"> <font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">No </font></label> </td> </tr> <tr> <td height="88"><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">¿QUÉ TIPO DE COBERTURA DE SEGURO LE INTERESA?<br> <textarea name="Type of Insurance" cols="45" rows="2" id="Type of Insurance"></textarea> </font></strong></td> </tr> <tr> <td><strong><font color="#FFFFFF" size="3" face="Arial, Helvetica, sans-serif">PREGUNTAS O COMENTARIOS ADICIONALES:<br> <textarea name="Questions or Comments" cols="65" rows="10" id="Questions or Comments"></textarea> <br> <br> <input type="submit" name="Submit" value="Enviar"> </font></strong></td> </tr> </table> </form> </td> </tr> </table> <p><br> </p> </div> </body> </html>