<form method="post" action="http://www.mockupblog.com/concierge/wp-login.php" name="loginform">
<div class="hiddenFields">
<input type="hidden" name="XID" value="91bf7c2ae8c23d867bc50e6a27e84671f5d393fb">
<input type="hidden" name="ACT" value="14">
<input type="hidden" name="RET" value="provider/index">
<input type="hidden" name="site_id" value="1">
<input type="hidden" name="redirect-to" value="http://www.mockupblog.com/wp-admin/edit.php?posttype=ccalisting">
<input type="hidden" name="testcookie" value="1">
</div>
<div style="float:left; width:200px;color:#666666;">Your Username:</div>
<div style="float:left; width:400px;">
<input type="text" name="log" id="username" style="width:400px; padding:5px;"></div>
<div class="clear_both" style="height:15px;"></div>
<div style="float:left; width:200px;color:#666666;">Your Password:</div>
<div style="float:left; width:400px;">
<input type="password" name="pwd" id="password" style="width:400px; padding:5px;"></div>
<div class="clear_both" style="height:15px;"></div>
<div style="float:left;padding-left:199px;">
<input type="checkbox" name="rememberme" id="auto_login" value="1" style="width:10px;padding:0px;"> <label for="auto_login">Auto-login on future visits?</label></div>
<div style="text-align:right; width:600px;">
<a href="http://www.conciergecareadvisors.com/provider/forgot_password">Forgot Password?</a></div>
<div class="clear_both" style="height:15px;"></div>
<div style="float:left; width:400px;">
</div>
<div id="contact" style="background-color:transparent; text-align:right; margin-right:75px;">
<input type="submit" name="submit" class="submit" value="Login" style="width:120px;background-color:#edc100;"></div>
</form>