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<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=210 BGCOLOR="#660033" TEXT="#F7F7FF"> <div> <A HREF="index.htm" TARGET="_top" TITLE="Traveling Chiropractors International"><U><IMG SRC="tci-25year-logo.png" border=0 width="168" height="200" ALIGN="BOTTOM" HSPACE="10" VSPACE="0"></U></A></div> <div> (800)624-8876</div> <div>   <IMG SRC="0671ba00.png" border=0 width="27" height="160" ALIGN="BOTTOM" HSPACE="28" VSPACE="0"></div> <bR> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Request Information</I></div> <div> <IMG SRC="062f4710.png" border=0 width="500" height="113" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="Traveling Chiropractors International"><U>Home</U></A></div> <div>  <FORM ACTION="form.php" METHOD="post"> Doctor's First Name: <input type=text name=first><br> Doctor's Last Name: <INPUT TYPE=text NAME=last><br> Email Address: <INPUT TYPE=text NAME=email><br> Office Address: <INPUT TYPE=text NAME=address size=30><br> Phone Number: <INPUT TYPE=text NAME=phone size=12><br> Fax Number: <INPUT TYPE=text NAME=fax size=12><br> Dates needing a doctor: <INPUT TYPE=text NAME=dates><br> Estimated Average Number Patients a Week: <INPUT TYPE=text NAME=patients size=5><br> Days a Week: <INPUT TYPE=text NAME=days><br> Techniques Used: <INPUT TYPE=text NAME=tech><br> Office Hours: <INPUT TYPE=text NAME=hours><br> <INPUT TYPE="submit" VALUE="Send Information"> </FORM>  </div> <bR> <div> We look forward to working with you! </div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> All States</div> <bR> <div> <B>(800)624-8876</B></div> <div> <B>Fax (816)941-9574</B></div> <bR> <div> <B>Traveling Chiropractors International</B></div> <div> <B>412 West 101st Terrace</B></div> <div> <B>Kansas City, MO 64114</B></div> <bR> <div> <A HREF="mailto:harry@travelingchiropractors.com" TARGET="_top" TITLE="mailto:hllane1048@yahoo.com"><U><B>harry@travelingchiropractors.com</B></U></A></div> </td> </tr></table></body>