Metacat

            <option>Colorado</option>

            <option>Connecticut</option>

            <option>Delaware</option>

            <option>Federated States of Micronesia</option>

            <option>Florida</option>

            <option>Georgia</option>

 [% END %]

 <input type="hidden" name="keyCount" value="[%numKey%]" 

            id="keyCount">

 <table cellspacing="0" border="0" cellpadding="9" width="760"

bgcolor="#c6d6e7">

    <tr> 

            <td>

            [% SET keyTh = "kwTh${cnt}" %]

            <select name="kwTh[%cnt%]">

	     	<option selected>[%$keyTh%]</option>

	    [% END %]

	    <option>none</option>

          [% ELSE %]

		<b>Month (MM)</b></font></p>

	  [% END %]

      </td>

      <td width="33%" valign="TOP"> 

        <p><font size="-1">

          [% ELSE %]

	          <b>Day (DD)</b></font></p>

	  [% END %]

      </td>

    </tr>

    <tr> 

            <option>24</option>            <option>25</option>            <option>26</option>            <option>27</option>

            <option>28</option>            <option>29</option>            <option>30</option>            <option>31</option>

          </select>

      </td>

    </tr>

  </table>

            <option>Wisconsin</option>

            <option>Wyoming</option>

          </select>

          <input type="TEXT" name="origStateOtherContact" id="contactStateOther" value="[%origStateOtherContact%]">

          <b>Other State or Province</b>

          </p>