<table>
<tbody>
<tr>
<th>URL</th>
<td> </td>
</tr>
<tr>
<th>NAME</th>
<td> </td>
</tr>
<tr>
<th>TEL</th>
<td> </td>
</tr>
<tr>
<th>E-MAIL</th>
<td> </td>
</tr>
<tr>
<th>COMMENT</th>
<td> </td>
</tr>
</tbody>
</table>
<div class="submit"> </div>