<!-- Formulário -->
<style>body {background-color: transparent !important; } </style>
   <link rel='stylesheet' href='https://blob.llimages.com/machine-files/all-css/form-ll.css'>
   <form action="https://paginas.rocks/Pages/Index/357258" method="post" >
   <input id="id" name="id" type="hidden" value="357258" />
   <input id="pid" name="pid" type="hidden" value="13475108" />
   <input id="list_id" name="list_id" type="hidden" value="357258" />
   <input id="provider" name="provider" type="hidden" value="leadlovers" />
   <label for="email">E-mail:</label>
   <input class="form-control form-ll" id="email" name="email" placeholder="Informe o seu email" type="text" />
   <label for="name">Nome:</label>
   <input class="form-control form-ll" id="name" name="name" placeholder="Informe o seu nome" type="text"  />
   <label for="state">Estado:</label>
   <input class="form-control form-ll" id="state" name="state" placeholder="Informe seu estado" type="text"  />
   <label for="phone">Telefone:</label>
   <input class="form-control form-ll" id="phone" name="phone" placeholder="Informe o telefone" type="text" />
   <button class="btn btn-danger" style="padding: 10px 40px; margin:15px 0 5px;  " type="submit">Enviar</button>
   <input type="hidden" id="source" name="source" value="" />
   <img src="https://llimages.com/redirect/redirect.aspx?A=V&p=13475108&m=357258" style="display: none;" />
</form>