?>
<table border="0" width="100%">
	<tr>
		<td width="325">
		<P align="right">
Name of the farm, orchard, event, etc:*</td>
		<td>  <INPUT NAME="farmname" SIZE=56 MAXLENGTH=60 style="background-color: #CCFFFF"></td>
	</tr>
	<tr>
		<td align="right" width="325">Location - physical address..........* :</td>
		<td><INPUT NAME="addr1" SIZE=56 MAXLENGTH=50 style="background-color: #CCFFFF"></td>
	</tr>
	<tr>
		<td align="right" width="325">Address line 2, if needed:</td>
		<td><INPUT NAME="addr2" SIZE=56 MAXLENGTH=50 style="background-color: #FFFFCC"></td>
	</tr>
	<tr>
		<td align="right" width="325">&nbsp;City*:</td>
		<td><INPUT NAME="city" SIZE=30 MAXLENGTH=50 style="background-color: #CCFFFF"></td>
	</tr>
	<tr>
		<td align="right" width="325">State*:</td>
		<td><select size="1" name="state">
  <option selected>Select your state</option>
  <option value="AL">Alabama</option>
  <option value="AK">Alaska</option>
  <option value="AZ">Arizona</option>
  <option value="AR">Arkansas</option>
  <option value="CA">California</option>
  <option value="CO">Colorado</option>
  <option value="CT">Connecticut</option>
  <option value="DE">Delaware</option>
  <option value="DC">District of Columbia</option>
  <option value="FM">Federated States of Micronesia</option>
  <option value="FL">Florida</option>
  <option value="GA">Georgia</option>
  <option value="HI">Hawaii</option>
  <option value="ID">Idaho</option>
  <option value="IL">Illinois</option>
  <option value="IN">Indiana</option>
  <option value="IA">Iowa</option>
  <option value="KS">Kansas</option>
  <option value="KY">Kentucky</option>
  <option value="LA">Louisiana</option>
  <option value="ME">Maine</option>
  <option value="MH">Marshall Islands	</option>
  <option value="MD">Maryland</option>
  <option value="MA">Massachusetts</option>
  <option value="MI">Michigan</option>
  <option value="MN">Minnesota</option>
  <option value="MS">Mississippi</option>
  <option value="MO">Missouri</option>
  <option value="MT">Montana</option>
  <option value="NE">Nebraska</option>
  <option value="NV">Nevada</option>
  <option value="NH">New Hampshire</option>
  <option value="NJ">New Jersey</option>
  <option value="NM">New Mexico</option>
  <option value="NY">New York</option>
  <option value="NC">North Carolina</option>
  <option value="ND">North Dakota</option>
  <option value="MP">Northern Mariana Islands</option>
  <option value="OH">Ohio</option>
  <option value="OK">Oklahoma</option>
  <option value="OR">Oregon</option>
  <option value="PA">Pennsylvania</option>
  <option value="PR">Puerto Rico</option>
  <option value="RI">Rhode Island</option>
  <option value="SC">South Carolina</option>
  <option value="SD">South Dakota</option>
  <option value="TN">Tennessee</option>
  <option value="TX">Texas</option>
  <option value="UT">Utah</option>
  <option value="VT">Vermont</option>
  <option value="VI">Virgin Islands</option>
  <option value="VA">Virginia</option>
  <option value="WA">Washington</option>
  <option value="WV">West Virginia</option>
  <option value="WI">Wisconsin</option>
  <option value="WY">Wyoming</option>
</select></td>
	</tr>
	<tr>
		<td align="right" width="325">Zip code *:</td>
		<td><INPUT NAME="zip" SIZE=5 MAXLENGTH=5 style="background-color: #CCFFFF"></td>
	</tr>
	<tr>
		<td align="right" width="325">County the farm is in*:</td>
		<td><INPUT TYPE=TEXT NAME="county" SIZE=30 MAXLENGTH=30 style="background-color: #CCFFFF"></td>
	</tr>
	<tr>
		<td align="right" width="325">Country *:</td>
		<td> <select size="1" name="country">
<option selected value="USA">USA</option>
<option value="Australia">Australia</option>
<option value="Canada">Canada</option>
<option value="New Zealand">New Zealand</option>
<option value="South Africa">South Africa</option>
<option value="United Kingdom">United Kingdom</option>
<option value="Other">Other</option>
&nbsp;
</select></td>
	</tr>
	<tr>
		<td align="right" width="325">Phone number for information*:</td>
		<td>
		<INPUT NAME="phone" SIZE=22 MAXLENGTH=14 style="background-color: #CCFFCC"></td>
	</tr>
	<tr>
		<td align="right" width="325">Fax number:</td>
		<td><INPUT NAME="fax" SIZE=18 MAXLENGTH=14 style="background-color: #FFFFCC"></td>
	</tr>
	<tr>
		<td align="right" width="325">Farms email address<b>:</b></td>
		<td>
		<INPUT NAME="farmemail" SIZE=50 MAXLENGTH=50 style="background-color: #CCFFCC"></td>
	</tr>
</table>
<?php