<table width="100%">
	<form name="sendNewsletterSubscription" method="post" action="">
                <tr>
                  <td width="140" align="right">__%MAILING_LIST_LABEL%__</td>
                  <td width="1">&nbsp;</td>

                  <td width="259" align="left">
										<select name="ml_id" style="width: 80px;">
										__%MAILING_LIST_SELECTION%__
										</select>
									</td>
                </tr>
								<tr>
									<td style="height:20px;" colspan="3">&nbsp;</td>
								</tr>

                <tr>
                  <td width="140" align="right">__%LASTNAME_LABEL%__*</td>
                  <td width="1">&nbsp;</td>
                  <td width="259" align="left"><input type="text" name="last" size="50" value="__%LASTNAME%__"></td>
                </tr>
                <tr>
                  <td width="140" align="right">__%FIRSTNAME_LABEL%__*</td>
                  <td width="1">&nbsp;</td>
                  <td width="259" align="left"><input type="text" name="first" size="50" value="__%FIRSTNAME%__"></td>
                </tr>
                <tr>

                  <td width="140" align="right">__%EMAIL_LABEL%__*</td>
                  <td width="1">&nbsp;</td>
                  <td width="259" align="left"><input type="text" name="address" size="50" value="__%EMAIL%__"></td>
                </tr>
                <tr>
                  <td colspan="5" height="0" style="padding-top: 30px;">
                      <br />
                      <center><i>__%LANG_LEGAL_NOTICE%__</i></center><br />
                    <div style="display: none;">
                      <select name="action" style="line-height: 13px; height: 18px; font-size: 11px; font-family: Arial, Helvetica, sans-serif; border: solid 1px #6466cc;">
  			                  <option value="subscribe" selected>Subscribe</option>
            			        <option value="unsubscribe">Unsubscribe</option>
                   		</select>
                    </div>
                   </td>

                </tr>
                <tr>
                  <td colspan="5" height="44"> <div align="center"><input type="submit" value=" &nbsp;&nbsp;&nbsp;&nbsp; __%VALIDATE_BUTTON_LABEL%__ &nbsp;&nbsp;&nbsp;&nbsp; " /></div></td>
                </tr>
	</form>
</table>