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please help for simple form. score submission

hotbullet 18 Apr, 2012

hi friends,

i have posted on professional request but no answers, so i think it might not be that difficult.
can any one please help me to this kind of form it is really important for me.

http://s1250.photobucket.com/albums/hh536/hotbullet79/?action=view¤t=form.jpg

thanks

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