<form action="http://leadpoint.energysmart.com.au/api/in" method="post" >
<input type="hidden" name="source" value="ebd296a" />
<div class="form-group">
  <label for="full_name">Full name</label>
  <input type="text" class="form-control" name="full_name" placeholder="Full name" >
</div>
<div class="form-group">
  <label for="email">Email</label>
  <input type="text" class="form-control" name="email" placeholder="Email" >
</div>
<div class="form-group">
  <label for="phone">Phone number</label>
  <input type="text" class="form-control" name="phone" placeholder="Phone number" >
</div>
<div class="form-group">
  <label for="roof_type">Type of Roof</label>
  <input type="text" class="form-control" name="roof_type" placeholder="Type of Roof" >
</div>
<div class="form-group">
  <label for="address">Address</label>
  <input type="text" class="form-control" name="address" placeholder="Address" >
</div>
<div class="form-group">
  <label for="system_size">System size</label>
  <input type="text" class="form-control" name="system_size" placeholder="System size" >
</div>
<div class="form-group">
  <label for="house_type">Type of house</label>
  <input type="text" class="form-control" name="house_type" placeholder="Type of house" >
</div>
<div class="form-group">
  <label for="system_for">System for</label>
  <input type="text" class="form-control" name="system_for" placeholder="System for" >
</div>
<div class="form-group">
  <label for="electricity">Electricity provider</label>
  <input type="text" class="form-control" name="electricity" placeholder="Electricity provider" >
</div>
<div class="form-group">
  <label for="house_age">Age of current house</label>
  <input type="text" class="form-control" name="house_age" placeholder="Age of current house" >
</div>
<div class="form-group">
  <label for="country">Country</label>
  <input type="text" class="form-control" name="country" placeholder="Country" >
</div>
<div class="form-group">
  <label for="city">City</label>
  <input type="text" class="form-control" name="city" placeholder="City" >
</div>
<div class="form-group">
  <label for="state">State</label>
  <input type="text" class="form-control" name="state" placeholder="State" >
</div>
<div class="form-group">
  <label for="postcode">Post Code</label>
  <input type="text" class="form-control" name="postcode" placeholder="Post Code" >
</div>
<div class="form-group">
  <label for="suburb">Suburb</label>
  <input type="text" class="form-control" name="suburb" placeholder="Suburb" >
</div>
<div class="form-group">
  <label for="note">Notes</label>
  <input type="text" class="form-control" name="note" placeholder="Notes" >
</div>
<input type="submit" class="btn btn-primary" value="SUBMIT">
</form>