{exp:freeform:form
        form_name="exclusive-signup"
        form:id="exclusive-signup-form"
        return="{segment_1}/thank_you"
        notify="me@thedomain.com"
    }
    <fieldset>
        <ul class="form-list">
            <li>
                <label>First Name</label>
                <div class="input-box">
                    <input class="input-text" type="text" maxlength="150" id="freeform_first_name" value="" name="first_name">
                </div>
            </li>
            <li>
                <label>Last Name</label>
                <div class="input-box">
                    <input class="input-text" type="text" maxlength="150" id="freeform_last_name" value="" name="last_name">
                </div>
            </li>
            <li>
                <label>Email</label>
                <div class="input-box">
                    <input class="input-text" type="text" maxlength="150" id="freeform_email" value="" name="email">
                </div>
            </li>
            <li>
                <label>Message</label>
                <div class="input-box">
                    <textarea class="textarea" id="freeform_user_message" rows="6" cols="50" name="user_message"></textarea>
                </div>
            </li>
            {if freeform:captcha}
            <li>
                <p>Please enter the word you see in the image below:</p>
                <div class="input-box">
                    <p>{freeform:captcha}</p>
                    <input type="text" name="captcha" style="width:140px;" />
                </div>
            <li>
            {/if}
            <li class="buttons-set">
            <button class="button" type="button"><span><span>Sign Up</span></span></button>
            </li>
        </ul>
    </fieldset>
    {/exp:freeform:form}
</div>
{/exp:stash:set}{/exp:channel:entries}