<br /><span class="contentheading">Free Trial</span>
<br /><br />
<img align="left" style="padding-right:8px" src="http://www.30minutehit.com/franchise/fitness-franchise.jpg" />
<div style="background-color:#F0F0F0;border-color:#CFCFCF;border-style:solid;border-width:1px;float:right">
<div class="form_item">
  <div class="form_element cf_textbox">
    <label class="cf_label" style="width: 100px;">Name</label>
    <input class="cf_inputbox required" maxlength="150" size="30" title="please select name" id="text_0" name="text_0" type="text" />
  
  </div>
  <div class="cfclear">&nbsp;</div>
</div>



  
  
  <div class="cfclear">&nbsp;</div>


<div class="form_item">
  <div class="form_element cf_textbox">
    <label class="cf_label" style="width: 100px;">Phone</label>
    <input class="cf_inputbox" maxlength="150" size="30" title="{cf_title}" id="text_6" name="text_6" type="text" />
  
  </div>
  <div class="cfclear">&nbsp;</div>
</div>

<div class="form_item">
  <div class="form_element cf_textbox">
    <label class="cf_label" style="width: 100px;">Email</label>
    <input class="cf_inputbox validate-email" maxlength="150" size="30" title="" id="text_4" name="text_4" type="text" />
  
  </div>
  <div class="cfclear">&nbsp;</div>
</div>

<div class="form_item">
  <div class="form_element cf_dropdown">
    <label class="cf_label" style="width: 100px;">Location</label>
    <select class="cf_inputbox validate-selection" id="select_10" size="1" title="{cf_title}"  name="USERNAME">
    <option value=""></option>
<option value="Abbotsford">Abbotsford</option>
<option value="Burnaby">Burnaby</option>
<option value="Edmonton">Edmonton</option>
<option value="Langley">Langley</option>
<option value="Maple Ridge">Maple Ridge</option>
<option value="North Vancouver">North Vancouver</option>     
<option value="Port Coquitlam">Port Coquitlam</option>
<option value="Richmond">Richmond</option>
<option value="South Surrey">South Surrey</option>
<option value="Spanaway">Spanaway</option>
<option value="Vancouver">Vancouver</option>







    </select>
    
  </div>
  <div class="cfclear">&nbsp;</div>
</div>

<div class="form_item">
  <div class="form_element cf_textarea">
    <input class="cf_hidden" size="30" id="Referer_url" name="Referer_url" value="<?php echo $_SERVER['HTTP_REFERER']; ?>" type="hidden" />
<input class="cf_hidden" size="30" id="radio" name="radio" value="T-Show" type="hidden" />
  </div>
  <div class="cfclear">&nbsp;</div>
</div>

<div class="form_item">
  <div class="form_element cf_button">
    <input value="Submit" name="{cf_name}" type="submit" />
  </div>
  <div class="cfclear">&nbsp;</div>
</div>
</div>
