Application Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="09ed05a3.jpg"> <div> <FONT SIZE="2" COLOR="#000000" FACE="Arial" ><B>          </B></FONT><FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>                             </B></FONT><FONT SIZE="5" COLOR="#FF0000" FACE="Arial" ><B>    Reading Council for Voluntary Youth Service</B></FONT><B>    </B><B> </B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="09fd2123.jpg"> <div>                                                   </div> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE=" Reading Council for Voluntary Youth "><U><B>Home</B></U></A></div> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Application Form</I></div> <div>  <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,Email,GroupName,Address1,Role,CourseDetails,Cost,Bursary,Benefit,Phone"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your bursary application. We will contact you shortly."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A bursary application form was submitted"><input type="hidden" name="tlx_EmailTo" value="cathb@rcvys.org.uk"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Name of Person applying for bursary:<br> <input type="text" name="FirstName" size="100" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="100" maxlength="100"></td> </tr> <tr> <td align="left">Group Name:<br> <input type="text" name="GroupName" size="100" maxlength="100"></td> </tr> <tr> <td align="left">Contact Address for Communication:<br> <input type="text" name="Address1" size="100" maxlength="200"></td> </tr> <tr> <td align="left">Your role in group:<br> <input type="text" name="Role" size="100" maxlength="200"></td> </tr> <tr> <td align="left">Details of Course (name, venue, date):<br> <input type="text" name="CourseDetails" size="100" maxlength="200"></td> </tr> <tr> <td align="left">Cost of course/training:<br> <input type="text" name="Cost" size="100" maxlength="100"></td> </tr> <tr> <td align="left">Amount of bursary applied for:<br> <input type="text" name="Bursary" size="100" maxlength="100"></td> </tr> <tr> <td align="left">How will this help the children/young people in your group:<br> <textarea name="Benefit" rows="10" cols="100"></textarea></td> </tr> <tr> <td align="left">Phone Number (in case we need more info):<br> <input type="text" name="Phone" size="100" maxlength="100"></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </div> </td> </tr></table></body>