<!--includeForm-->

<style type="text/css">
body, html {padding:0; margin:0; font:normal 12px Arial,Helvetica,sans-serif; color:#3C3C3C;}
form {margin:0;}
</style>



<form method="post">




 
Телефон:<br /><input type="text" size="30" maxlength="100" value="" name="d[0]" id="d[0]" />

<br /><br />





 

<style>img.captcha {
border:1px solid gray;
}</style>


<SPAN style="color:red">*</SPAN>Введите код изображенный на картинке:<br>

<img class="captcha" src="http://captcha.oml.ru/captcha.php?hash=sRki%2BoQ5fS%2Fsug%3D%3D&key=12ebf46c05c9f313e5058c0ff94409fc&id=cms&format=.gif" height="50" align="absmiddle">&nbsp;&nbsp;<input type="text" size="5" maxlength="4" name="_cn">

<input type="hidden" value="12ebf46c05c9f313e5058c0ff94409fc" name="_cs"><br>


<br clear="all">

<input type="submit" value="Отправить"></form>





<script src="/shared/misc/calendar.gen.js" type="text/javascript" language="javascript" charset="utf-8"></script>
<!--includeForm-->
&nbsp;