<table width="400" border="0" cellspacing="0" cellpadding="0" style="border: solid 1px; font-size: 12px;">
<tr>
<td><img src="http://affiliate.dtiserv.com/sam/form/goa/images/01.jpg" width="193" height="40"></td>
<td><img src="http://affiliate.dtiserv.com/sam/form/goa/images/02.gif" width="207" height="40"></td>
</tr>
<tr>
<td valign="top"><img src="http://affiliate.dtiserv.com/sam/form/goa/images/03.jpg" width="193" height="260"></td>
<td background="http://affiliate.dtiserv.com/sam/form/goa/images/back.jpg">
<form action="https://www.dtiserv3.com/cgi-bin/free_join.fcgi" method="post" name="join_form" target="_blank" style="width: 207px; margin-bottom: -7px;">
<input type="hidden" name="goods_id" value="1012903">
<input type="hidden" name="lang" value="ja">
<input type="hidden" name="action" value="join_confirm">
<input type="hidden" name="aff_id" value="xxx">
<p style="padding-left:20px;"><font style="font-size: 80%; padding-left: 95px;"><br>
<font color="#000000">ユーザー名：<br>
<input name="username" type="text" size="30" style="background: tranceparent;">
</p>
<p style="padding-left:20px; margin-top: -10px;"> <font color="#000000">パスワード：<br>
<input name="password" type="text" size="30" style="background: tranceparent;">
</p>
<p style="padding-left:20px; margin-top: -10px;"><font color="#000000"> メールアドレス：<br>
<input name="email" type="text" size="30" style="background: tranceparent;">
</p>
<p style="padding-left:20px; margin-top: -10px;"><font color="#000000"> メールアドレス（確認）：<br>
<input name="email2" type="text" size="30" style="background: tranceparent;">
</p>
<p style="padding-left:15px; margin-top: -10px;"><font color="#0000CC" style="font-size: 80%;">　※１００円以外の請求は一切ありません。<br>
　※登録にはクレジットカードが必要です。</font><br>
<input name="imageField" type="image" src="http://affiliate.dtiserv.com/sam/form/goa/images/button.gif" width="187" height="47" border="0">
</p>
</form>
</td>
</tr>
</table>