<form action="https://app.mailtru.com/lists/jw8149ydhr535/subscribe" method="post">
<div class="box box-primary borderless">
<div class="box-header">
<h3 class="box-title">Web Design Survey</h3>
</div>
<div class="box-body">
<div class="callout callout-info">We're happy you decided to subscribe to our email list.<br/>
Please take a few seconds and fill in the list details in order to subscribe to our list.<br/>
You will receive an email to confirm your subscription, just to be sure this is your email address.</div>
<div class="form-group field-text wrap-address">
<label for="ListFieldValue_value" class="required">Address <span class="required">*</span></label> <input class="form-control field-address field-type-text" placeholder="Address" type="text" value="" name="ADDRESS" id="ADDRESS"/> </div>
<div class="form-group field-text wrap-email">
<label for="ListFieldValue_value" class="required">Email <span class="required">*</span></label> <input class="form-control field-email field-type-text" placeholder="Email" type="text" value="" name="EMAIL" id="EMAIL"/> </div>
<div class="form-group field-multiselect wrap-site_reason">
<label for="ListFieldValue_value" class="required">I want this site because? <span class="required">*</span></label> <select class="form-control field-site_reason field-type-multiselect" placeholder="I want this site because?" multiple="multiple" size="1" name="SITE_REASON[]" id="SITE_REASON">
<option value="Yes">I need to offer a contact point to my clients</option>
</select> </div>
<div class="form-group field-text wrap-fname">
<label for="ListFieldValue_value" class="required">First name <span class="required">*</span></label> <input class="form-control field-fname field-type-text" placeholder="First name" type="text" value="" name="FNAME" id="FNAME"/> </div>
<div class="form-group field-text wrap-lname">
<label for="ListFieldValue_value" class="required">Last name <span class="required">*</span></label> <input class="form-control field-lname field-type-text" placeholder="Last name" type="text" value="" name="LNAME" id="LNAME"/> </div>
<div class="form-group field-text wrap-phone">
<label for="ListFieldValue_value" class="required">Phone Number <span class="required">*</span></label> <input class="form-control field-phone field-type-text" placeholder="Phone Number" type="text" value="" name="PHONE" id="PHONE"/> </div>
<div class="form-group field-text wrap-com_name">
<label for="ListFieldValue_value">Company Name</label> <input class="form-control field-com_name field-type-text" placeholder="Company Name" type="text" value="" name="COM_NAME" id="COM_NAME"/> </div>
<div class="form-group field-textarea wrap-com_activity">
<label for="ListFieldValue_value" class="required">What Does Your Company Do? <span class="required">*</span></label>
<textarea class="form-control field-com_activity field-type-textarea" placeholder="What Does Your Company Do?" name="COM_ACTIVITY" id="COM_ACTIVITY"/></textarea>
</div>
</div>
<div class="box-footer">
<div class="pull-right"><input type="submit" class="btn btn-primary btn-flat" name="yt0" value="Subscribe"/></div>
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