Untitled

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
<head>
<meta http-equiv="content-type" content="text/html; charset=UTF-8">
<title> Example Web Page</title>
</head>
<body>
<a href="http://users.skynet.be/mgueury/mozilla/">
  <img src="http://users.skynet.be/mgueury/mozilla/tidy_16.gif" alt="Validated by HTML Validator (based on Tidy) " height="16" width="39"/>
</a>

		<!-- Set the form action, including an optional message or page for your customer.-->
<form action="https://api.five9.com/web2campaign/AddToList?">

		<!-- Add the required hidden fields:
			- F9domain name
	 		- F9list Web2Campaign list
			- number1 (provided by user in the Web form below) -->
	<input type="hidden" name="F9domain" value="Airtite">
	<input type="hidden" name="F9list" value="Test_destination">

		<!-- Add optional hidden fields:
			- F9retURL: fully qualified URL to display the result.
			- F9retResults: set to 1 to append a result code to the result.
			- F9updateCRM: set to 1 to update all the fields in the list.
			- F9CallASAP: set to 1 to dial the number as soon as possible.
			- F9TimeToCAll: set the date and time to call the number.
			- F9TimeFormat: set the time format if you are using the F9TimeToCall parameter. -->
	<input type="hidden" name="F9retURL" value="Your_Return_URL">
	<input type="hidden" name="F9retResults" value="1">
	<input type="hidden" name="F9updateCRM" value="1">
	<input type="hidden" name="F9CallASAP" value="1">
	<input type="hidden" name="F9TimeToCAll" value="call time">
	<input type="hidden" name="F9TimeFormat" value="call time format">

		<!-- In the user input fields, the phone number is required. Be sure to match the case of the
			 Web2Campaign parameter name to the field name in the Administrator VCC. -->
	<table summary="Text fields that customers see">
			<tbody>
			   <tr>
			      <td>First Name</td>
	  		      <td><input id="first_name" maxLength="60" name="first_name"></td></tr>
	  		   <tr>
				  <td>Last Name</td>
				  <td><input id="last_name" maxLength="60" name="last_name"></td></tr>
	  		   <tr>
				  <td>Company</td>
				  <td><input id="company" maxLength="60" name="company"></td></tr>
	  		   <tr>
				  <td>Phone</td>
				  <td><input id="number1" maxLength="40" name="number1"></td></tr>
	  		   <tr>
				  <td>Address</td>
				  <td><textarea name="street" rows="3" cols="30"></textarea></td></tr>
	  		   <tr>
				  <td>City</td>
				  <td><input id="city" maxLength="20" name="city"></td></tr>
	  		   <tr>
				  <td>State/Province</td>
				  <td><input id="state" maxLength="20" name="state"></td></tr>
	  		   <tr>
				  <td>ZIP</td>
				  <td><input id="zip" maxLength="20" name="zip"></td></tr>
				<tr>
				  <td>Quin_Key</td>
				  <td><input id="zip" maxLength="20" name="Quin_Key"></td></tr>
			</tbody>
	</table>
	<input type="submit" name="submit" value="Submit Data">
</form>
</body>
</html>