Name:  free_sample_new.png
<vb:if condition=
Views: 39 Size: 118.3 KB" style="float: CONFIG" /> link is in Spanish, but here’s what it looks like translated.
Nombre -First Name
Apellido -Last Name
Direccion -Address
Ciudad -City
Estado -State
Correo Electronico -email
Fecha de Nacimiento -birthdate

Thank you for requesting your free sample Belmora LLC.

You will receive your free sample of Analgesic Tablets Flanax within 4 to 8 weeks.

Muestra Gratis Flanax: Analgsico para aliviar el dolor gratis por correo