<form enctype='multipart/form-data' action='process.php' method='post'>
<table border="1" cellspacing="1" style="border-collapse: collapse" bordercolor="#000066" width="95%" cellpadding="5">
<tr>
<td colspan="3" bgcolor="#B5CBEF" height="17" width="100%" bordercolor="#FFFFFF" background="tile_back.gif">
<p align="left\><b><font face="Verdana" size="2" color="#FFFFFF"><img border="0" src="nav_m.gif" width="8" height="8">
<font face='Verdana' size=2 color='#FFFFFF'><b>
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&nbsp;
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</tr><tr><td colspan="3" bgcolor="#B5CBEF" height="16" width="100%" bordercolor="#FFFFFF" background="tile_sub.gif"><font size="2" face="Verdana"><b><font face="Verdana" size="2" color="#000066">
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</font></b></font></td></tr><tr><td colspan="3" bgcolor="#D6DFEF" height="16" width="100%" bordercolor="#FFFFFF"><font size="1" face="Verdana">Please fill in all fields marked with a *</font></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Locat&aacute;rio</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='LOC' size=50>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Data de Nasc. </td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='DN' size=10>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td><td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">RG</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='RG' size=15></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Org&atilde;o Emissor </td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='ORG' size=7></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td><td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">CPF</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='CPF' size=11>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td><td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">CNH</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='CNH' size=11>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Endere&ccedil;o</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='END' size=50>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td><td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">CEP</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='CEP' size=9></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Cidade</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='CID' size=20>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td><td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">UF</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='UF' size=2>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Bandeira Cart&atilde;o </td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='BCAR' size=15></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">N&uacute;mero Cart&atilde;o </td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='NCAR' size=16></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Validade</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='VAL' size=10></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td><td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">CSC</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='CSC' size=4></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Modelo</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='MOD' size=15>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Di&aacute;ria</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='DIARIA' size=10>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Km</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='KM' size=6></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Per&iacute;odo</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='PER' size=15>
* (25/2006 a 30/2007) </td>
</tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Forma de Pagto. </td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='FP' size=15>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Contato</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='CONTATO' size=20>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Telefone</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='TEL' size=17>*</td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">E-mail</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='EMAIL' size=40>
*</td>
</tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Data</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='DATA' size=10></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Hora</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='HORA' size=5></td></tr><tr><td height="30" width="55" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<img border="0" src="bc_new.gif" width="28" height="28"></td>
<td height="30" width="189" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana" size="2">Obs.:</td>
<td height="30" width="469" bgcolor="#EFF3F7" bordercolor="#FFFFFF">
<font face="Verdana"><input type=text name='OBS' size=50></td></tr><tr><td colspan="3" bgcolor="#B5CBEF" height="25" width="737" background="tile_sub.gif"><p align="center"><font face="Verdana" size="2"><input type=submit value='Enviar'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type=reset value='Limpar'>
</font></td></tr>
</table></form>