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<script>
	function SetTotal()
	{
		e = document.getElementById("NumBooks").value;
		document.getElementById("TotDue").value = e * 5;
	}
	
	function PrintPage()
	{
		window.print();
	}
	
</script>
<table width=100%>
	<tr>
		<td colspan=2>
<h>Utah's Gold Medal Miles Order Form<h>

Utah's Gold Medal Miles books can be ordered from the Utah Department of Health at a cost of 
<STRIKE>$10</STRIKE> <B>$5 + $2.50</B> shipping and handling.
<BR>
You can pick up your copy for just $5 at Utah Department of Health or you can mail a check for
$7.50 to the address below. 
<BR><BR>
</td>
</tr>
<tr>
<td>
1. Fill out the form<BR>
2. Print This Page<BR>
3. Mail with a check for $7.50 per book.<BR>

<BR>Send to:
<BR>Jane Lambert<BR>
Utah Department of Health/Heart Disease and Stroke Prevention Program<BR>
PO Box 142107<BR>
Salt Lake City, Utah 84114-2107<BR>
<BR><BR>
<table>
<tr>
<form>
<td>Name:</td><td><input type = text size=40></input></td>
</tr>
<tr>
<td>Address:</td><td><input type = text size=40></input></td>
</tr>
<tr>
<td>City:</td><td><input type = text size=40></input></td>
</tr>
<tr>
<td>Zip:</td><td><input type = text size=10></input></td>
</tr>
<tr>
<td>Number <BR>of Books:</td><td><input id="NumBooks" type = text size=10></input></td>
</tr>
<tr>
<td>Total Due: $</td><td><input type=text id="TotDue" onFocus="SetTotal();"  size=10></input></td>
</tr>
<!--
<tr>
<td><input type="Submit" value="Print Page" onClick="PrintPage();"></td><td><input type="Reset" value="Clear Form"></td>
</tr>
-->
</form
        </td>
      </tr>
    </table></td>
<td>
	Check out some sample pages of the book.
	<BR><a href="gmmsamples.php"><img src="/graphics/BookCover_sm.jpg"></a>
</td>
  </tr>
  <tr>
    <td height="46"><div align="center"><font size="1" face="Lucida Sans Unicode, Verdana, Tahoma, Arial, sans-serif">Brought to you by: <br>
          <a href="http://www.udot.utah.gov">Utah Department of Transportation</a> |          <a href="http://www.health.utah.gov">Utah
          Department of Health</a> |          <a href="http://www.checkyourhealth.org/">Check Your Health</a> | <a href="http://www.hearthighway.org/">The
          Alliance for Cardiovascular Health</a></font></div></td>
  </tr>
</table>
</body>
</html>