Untitled

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<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">

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<!--  NOTE: Please add the following <FORM> element to your page.             -->
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<form action="https://www.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST">

<input type=hidden name="oid" value="00D50000000awFB">
<input type=hidden name="retURL" value="http://www.americansforbreasthealth.com/pledge/thank-you">

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<!--  NOTE: These fields are optional debugging elements. Please uncomment    -->
<!--  these lines if you wish to test in debug mode.                          -->
<!--  <input type="hidden" name="debug" value=1>                              -->
<!--  <input type="hidden" name="debugEmail"                                  -->
<!--  value="ecurwen@curleycompany.com">                                      -->
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<label for="first_name">First Name</label><input  id="first_name" maxlength="40" name="first_name" size="20" type="text" /><br>

<label for="last_name">Last Name</label><input  id="last_name" maxlength="80" name="last_name" size="20" type="text" /><br>

<label for="email">Email</label><input  id="email" maxlength="80" name="email" size="20" type="text" /><br>

<label for="company">Company</label><input  id="company" maxlength="40" name="company" size="20" type="text" /><br>

<label for="city">City</label><input  id="city" maxlength="40" name="city" size="20" type="text" /><br>

<label for="state">State/Province</label><input  id="state" maxlength="20" name="state" size="20" type="text" /><br>

<input type="submit" name="submit">

</form>