<div align="center">

<table border="0" cellspacing="0" cellpadding="4">
<tr>
<th colspan="2">ACTIVATION INSTRUCTIONS</th>
</tr>
<tr>
<td align="right">Your email </td>
<td align="left" ><input type="text" name="email" class="input" size="30" maxlength="100" /></td>
</tr>
</table>

<br /><br />

<input class="button" type="submit" value=" SUBMIT " />

</div>