<form name="Shipping_Date">
   <input type=hidden name="required_fields" value="Month;Day">
  <table width="360" border="0" cellspacing="0" cellpadding="3" align="left">
    <tr> 
    <td bgcolor="#FFFFFF"> 
      <div align="left"><font color="#D7D6A8" face="Arial, Helvetica, sans-serif"><font size="2" color="#FF0000"><i><b>We 
        only ship September 1st through May 31st</b></i></font></font></div>
    </td>
  </tr>
  <tr> 
    <td bgcolor="#FFFFFF" width="388"><font face="Arial, Helvetica, sans-serif" size="2" color="#D7D6A8"><b><font color="#000000">Choose 
      your desired shipping date:</font></b></font> </td>
  </tr>
  <tr bgcolor="#829361" align="center" valign="top"> 
    <td align="left" bgcolor="#FFFFFF" valign="top"> 
      <select name="Month">
        <option selected>ASAP</option>
        <option>September</option>
        <option>October</option>
        <option>November</option>
        <option>December</option>
        <option>January</option>
        <option>February</option>
        <option>March</option>
        <option>April</option>
        <option>May</option>
      </select>
      <select name="Day">
        <option selected>ASAP</option>
        <option>1</option>
        <option>2</option>
        <option>3</option>
        <option>4</option>
        <option>5</option>
        <option>6</option>
        <option>7</option>
        <option>8</option>
        <option>9</option>
        <option>10</option>
        <option>11</option>
        <option>12</option>
        <option>13</option>
        <option>14</option>
        <option>15</option>
        <option>16</option>
        <option>17</option>
        <option>18</option>
        <option>19</option>
        <option>20</option>
        <option>21</option>
        <option>22</option>
        <option>23</option>
        <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>
</form>

