<table>
<tr> 
	<td><input type="text" name="firma"  size="41" maxlength="50" value=""  class="formm">
</tr>
	
<tr> 
	<td><input type="text" name="adr"  size="41" maxlength="70"  class="formm">
</tr>
	
<tr> 
	<td><input type="text" name="adr1"  size="41" maxlength="70"  class="formm">
</tr>
	
<tr>
	<td><input type="text" name="tel"  size="15" maxlength="15" value=""  class="formm">
</tr>
	
<tr> 
	<td><input type="text" name="tel1"  size="15" maxlength="15" value=""  class="formm">
</tr>
	
<tr>
	<td><input type="text" name="em"  size="41" maxlength="50"  class="formm">
</tr>
</table>