<form action="http://campaign.digitalmailmaker.com/index.php" class="contact" method="post" name="campaignform" onsubmit="return validate()" >
<input type="hidden" name="camp" value="websignup">
<input type="hidden" name="perso" value="V1RJNE9VMVhiR3RsYlVadlkwaFZOR0ZuUFQwPStV">

<div class="row_extra"><label class="formcol1">First Name:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="first_name"></span></div>

<div class="row_extra"><label class="formcol1">Last Name:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="last_name"></span></div>

<div class="row_extra"><label class="formcol1">Company:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="company_name"></span></div>

<div class="row_extra"><label class="formcol1">Address:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="address_1"></span></div>

<div class="row_extra"><label class="formcol1">City:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="city"></span></div>

<div class="row_extra"><label class="formcol1">State:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="state"></span></div>

<div class="row_extra"><label class="formcol1">Zip:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="zip"></span></div>

<div class="row_extra"><label class="formcol1">Email:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="email"></span></div>

<div class="row_extra"><label class="formcol1">Phone:&nbsp;</label>
<span class="formcol2"><input type="text" class="input" name="contact_phone"></span></div>

<div class="row_extra"><label class="formcol1">Comments:&nbsp;</label>
<span class="formcolcom"><textarea style=" font-size: 11px" name="comments" rows="5" cols="30"></textarea></span></div>

<div style="float: left; clear: both; width: 290px; margin-bottom: 10px; margin: 12px">
<p style="line-height: 12px; font-size: 10px">Please enter the security code shown in the graphic. If you can't read the code, click the image to generate a new one or contact your site admin.</p>
<div align="center">
<p style="line-height: 12px; font-size: 10px><a href="partner-opportunities.html" class="loginCaptcha">
<img id="captcha_image" src="/manager/includes/veriword.php?rand=2094418154" alt="Please enter the security code shown in the graphic. If you can't read the code, click the image to generate a new one.<br />" /></a>
</div>
<span style="line-height: 12px; font-size: 10px">Security code: <input type="text" name="captcha_code" tabindex="3" value="" /></span>
</p>
</div>
</div>

<div class="row_extra"><label class="formcol1">&nbsp;</label>
<span class="formcol2"><input type="submit" name="submit_form" value="Submit"></span></div>

</form>
