<!- 設置の際には必ずxxxをご自身のＩＤに変更して下さい ->
<TABLE
border=0 cellPadding=0 cellSpacing=0 background=http://affiliate.dtiserv.com/sam/form/dx2/index_dx5_files/bgpicd.jpg>
<TBODY>
<TR>
<TD colSpan=2 height=168></TD>
<TD width=17></TD>
<TD width=470></TD>
<TD width=50></TD></TR>
<TR>
<TD colSpan=3 height=16></TD>
<TD vAlign=top rowSpan=2>
<FORM name=join_form
action=https://www.dtiserv3.com/cgi-bin/free_join.fcgi method=post
target=_blank>
<DIV align=right><INPUT type=hidden value=1011903 name=goods_id> <INPUT
type=hidden value=ja name=lang> <INPUT type=hidden value=join_confirm
name=action> <INPUT type=hidden value=xxxx name=aff_id> <SPAN
style="FONT-SIZE: 16px; COLOR: white"><BR><STRONG>「キャンペーン申し込みフォーム」</STRONG><BR></SPAN></STRONG><SPAN
style="FONT-SIZE: 12px; COLOR: white">以下の項目をご記入下さい。<BR></SPAN></FONT><A
onclick="MM_openBrWindow('http://affiliate.dtiserv.com/sam/form/dxlive/index2a.html','','width=407,height=280')"
href="javascript:;"><SPAN
style="FONT-SIZE: 11px; COLOR: red"><STRONG>&gt;&gt;詳しい入力説明はこちら</STRONG></SPAN></A><BR><SPAN
style="FONT-SIZE: 12px; COLOR: white">ユーザー名 <INPUT maxLength=14
name=username> <BR>パスワード <INPUT maxLength=14 name=password> <BR>eメール
<INPUT maxLength=50 size=30 name=email> <BR>eメール確認 <INPUT maxLength=50
size=30 name=email2><BR><INPUT name=submit type=image
src="http://affiliate.dtiserv.com/sam/form/dx2/index_dx5_files/send.gif" width=147 height=28 border=0>
</SPAN></DIV></FORM></TD></TR>
<TR>
<TD height=275 cospan="4"></TD></TR></TBODY></TABLE>