<!--  ----------------------------------------------------------------------  -->
<!--  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">                                      -->
<!--  ----------------------------------------------------------------------  -->

<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>