Please fully complete the form below

and remember

To ensure that the music you request is played

it will need to be something that will keep the Dance floor full

as, let's face it, that is our aim !

 

 

 

Just click the play button above and I will tell you what to do

Music request form

<form method="post" enctype="multipart/form-data" action="http://pub19.bravenet.com/emailfwd/senddata.php">
<input type="hidden" name="usernum" value="1585679179">
<input type="hidden" name="cpv" value="2">
<!-- DO NOT CHANGE OR REMOVE THE 3 TAGS ABOVE THIS COMMENT-->

<table border="0" cellpadding="0" cellspacing="0" align="center">
<tr>
<td><h3 style="border-bottom:1px solid black;">Music request form</h3></td>
</tr>
<tr>
<td>
<label for="Name" style="float:left;width:140px;">Your name</label><input type="text" name="Name" id="Name" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>

<label for="replyemail" style="float:left;width:140px;">your email address</label><input type="text" name="replyemail" id="replyemail" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>

<label for="Function" style="float:left;width:140px;">Which function are you attending</label><input type="text" name="Function" id="Function" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>

<label for="date" style="float:left;width:140px;">Date i.e 12th July 2010</label><input type="text" name="date" id="date" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>

<label for="requests" style="float:left;width:140px;">Please type the tunes that you would like to hear at the function</label><textarea name="requests" id="requests" maxlength="" style="width:200px;height:160px;"></textarea><div style="clear:left;height:20px;"> </div>

</td>
<tr>
<td align="right">
<!-- YOU CAN MODIFY THE TEXT WITHIN VALUE="" TO MODIFY YOUR BUTTON TEXT-->
<input type="submit" value=" Submit "> <input type="reset" value=" Reset ">
</td>
</tr>
</table>
</form>