<script type="text/javascript" src="//contact-api.inguest.com/bundles/revinatecontactapi/js/revinate-form.js"></script>
<form id="revinate_contact_api_form" token="00000000-0000-0000-0000-0000000000000" onsubmit="revFormOnSubmit(); event.preventDefault();">
    <style scoped>
        label {display:inline-block; width:130px;}
        label.required:after { content:" *"; color: red;}
        fieldset {width:500px; padding:1em; border:3px solid #CCC;}
        input {margin: 1px 5px 1px 5px; width:145px; padding: 3px; border-width: 2px;}
        input.long {width: 300px}
        div.button {margin-top: 1em; text-align: center;}
    </style>
    <fieldset>
        <legend> Revinate Contact Sign Up Form Sample. </legend>
        <div>
            <label>First/ Last Name</label>
            <input type="text" name="first_name"/><input type="text" name="last_name"/>
        </div>
        <div>
            <label>Title, Gender</label>
            <input type="text" name="title"/><input type="text" name="gender"/>
        </div>
        <div>
            <label>Street Address</label>
            <input type="text" name="address_1"/><input type="text" name="address_2"/>
        </div>
        <div>
            <label>City, State</label>
            <input type="text" name="city"/><input type="text" name="state"/>
        </div>
        <div>
            <label>Country, Postal</label>
            <input type="text" name="country"/><input type="text" name="zip"/>
        </div>
        <div>
            <label>Phone Number</label>
            <input class="long" type="tel" name="phone"/>
        </div>
        <div>
            <label class="required">Email Address</label>
            <input class="long" type="email" name="email" required/>
        </div>
        <div>
            <label>Date of Birth</label>
            <input class="text" name="date_of_birth"/>
        </div>
        <div class="button">
            <button type="submit">Sign Me Up !</button>
        </div>
    </fieldset>
</form>