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<table border="0" cellspacing="0" width="450" align="center"> <form action="http://www.bltguernsey.com/index.php" method="post" name="online"> <input type="hidden" name="main_sub" value="63"> <input type="hidden" name="page_sub" value="7"> <input type="hidden" name="page_sub2" value="9"> <input type="hidden" name="part" value="2"> <tr> <td class="main" colspan="2"><b><font style="font-size: 14px;">Wills Data - Part One: Your Personal Details</font></b></td> </tr> <tr> <td class="main" colspan="2"><strong>I agree to the <a href="http://www.bltguernsey.com/images/site_files/16.pdf" target="_blank">Terms and Conditions</a></strong> Yes<input type="radio" name="terms_agree" value="Yes"> No<input type="radio" name="terms_agree" value="No" checked></td> </tr> <tr> <td class="main" colspan="2"><strong>Please note that fields marked with a <font color="#FF0000">*</font> are required.</strong></td> </tr> <tr> <td class="main"colspan="2"><strong>Personal Details</strong></td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font> Title</strong></td> <td class="main"> <select style="border: 1px solid #3A6E8F; color: #3A6E8F;" name="title"> <option value="" selected>Please select</option> <option value="Mr.">Mr.</option> <option value="Mrs.">Mrs.</option> <option value="Ms.">Ms.</option> <option value="Dr.">Dr.</option> </select> </td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font> Surname</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="surname" size="30"></td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font> Christian name(s)</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="christianname" size="30"></td> </tr> <tr> <td class="main" width="200"><strong>Full name given at birth if different from above</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="birthname" size="30"></td> </tr> <tr> <td class="main" width="200" valign="top"><font color="##FF0000">*</font> <strong>Your current address</strong></td> <td class="main"><textarea style="border: 1px solid #3A6E8F; color: #3A6E8F;" cols="24" rows="2" name="address"></textarea></td> </tr> <tr> <td class="main" width="200" colspan="2"><strong>Contact telephone numbers</strong></td> </tr> <tr> <td class="main" width="200"><font color="#FF0000">*</font> <strong>Home</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="homephone" size="30"></td> </tr> <tr> <td class="main" width="200"><strong>Work</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="workphone" size="30"></td> </tr> <tr> <td class="main" width="200"><strong>Mobile</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="mobilephone" size="30"></td> </tr> <tr> <td class="main" width="200"><font color="##FF0000">*</font> <strong>Email Address</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="email" size="30"></td> </tr> <tr> <td class="main" width="200" valign="top"><font color="##FF0000">*</font> <strong>Are you</strong></td> <td class="main"><input type="checkbox" name="areyou" value="Single"> Single<br> <input type="checkbox" name="areyou" value="Married"> Married<br> <input type="checkbox" name="areyou" value="Widowed"> Widowed<br> <input type="checkbox" name="areyou" value="Divorced"> Divorced<br> <input type="checkbox" name="areyou" value="Separated from your spouse"> Separated from your spouse<br> <input type="checkbox" name="areyou" value="Living with a partner"> Living with a partner</td> </tr> <tr> <td class="main" width="200"><strong>Maiden name or other names</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="maidenname" size="30"></td> </tr> <tr> <td class="main" width="200"><strong>Spouse's full name (if married)</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="spousename" size="30"></td> </tr> <tr> <td class="main" width="200"><strong>Father's name in full</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="fathersname" size="30"></td> </tr> <tr> <td class="main" width="200"><strong>Have you made a Will (or Wills) before?</strong></td> <td class="main"><select style="border: 1px solid #3A6E8F; color: #3A6E8F;" name="willbefore" size="1"> <option value="yes">Yes</option> <option value="no" SELECTED>No</option> </select></td> </tr> <tr> <td class="main" width="200"><strong>Does it relate to assets in Guernsey?</strong></td> <td class="main"><select style="border: 1px solid #3A6E8F; color: #3A6E8F;" name="assetsingsy" size="1"> <option value="yes">Yes</option> <option value="no" SELECTED>No</option> </select></td> </tr> </table><br> <table border="0" align="center"> <tr> <td class="main" align="center"><input style="border: 1px solid #3A6E8F; color: #3A6E8F; background-color: white;" type="submit" name="submit" value="Next"></td> </tr> </form> </table><br>
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