{template header}
{template top}
<div class="lvweba">
	<h1>积分兑换</h1>
</div>
<div class="lvwebb">
<form  action="index.php" method="post">
<table width="400" cellspacing="0" cellpadding="0" border="0" align="center" style="margin:auto;">
<input type="hidden" name="agid" value="{$agid}">
<input type="hidden" name="con" value="gift">
<input type="hidden" name="act" value="app">
<tr><td align="right" height="35px;">收件人:</td><td> <input type="text" name="name" class="q004"> </td></tr>
<tr><td align="right" height="35px;">手机号:</td><td> <input type="text" name="callnum" class="q004"> </td></tr>
<tr><td align="right" height="35px;">地址:</td><td> <input type="text" name="add" class="q004"> </td></tr>
<tr><td align="right" height="35px;">邮政编码:</td><td> <input type="text" name="zip" class="q004"> </td></tr>
<tr><td align="right" height="35px;">QQ号:</td><td> <input type="text" name="qq" class="q004"> </td></tr>
<tr><td colspan="2" align="center"> <input type="submit" value="确定"  class="t002">&nbsp;&nbsp;<input type="reset" value="重置"  class="t002"></td></tr>
</table>
</form>
</div>
{template foot}