WDC_Carl_Facebook

<form action="http://marketing.wdctravel.com/exec/affiliate_lead.php" id="optin-form" >
     <fieldset>
        <div class="field"><label>Name:</label><input type="text" id="FIRSTNAME" name="FIRSTNAME" value=""/></div>
        <div class="field"><label>E-mail:</label><input type="text" id="EMAIL" name="EMAIL" value=""/></div>
        <div class="field"><label>Phone:</label><input type="text" id="PHONE" name="PHONE" value=""/></div>
         <input type="hidden" name="SPONSORID" value="80" />
        <input type="hidden" name="CAMPAIGNID" value="444" />
        <input type="hidden" name="REDIRECT" value="{REDIRECT}" />
                <!-- REPLACE {REDIRECT} WITH THE URL YOU WISH THE VISITOR TO GO TO -->
        <!-- INSERT CAPTCHA CODE HERE IF NEEDED -->
        <input type="submit" id="sbtn" value="SUBMIT"></div>
    </fieldset>
</form>