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