<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Newsletter Subscription</title>
</head>
<body>
<h2>Newsletter Subscription</h2>
<link rel="stylesheet" type="text/css" href="http://www.emailmeform.com/builder/styles/dynamic.php?t=post" />
<script type="text/javascript" src="http://www.emailmeform.com/builder/js/dynamic.php?t=post&t2=0"></script>
<form id="emf-form" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/QWaG6hXkLa091284ZcdPd" name="emf-form">
<table style="text-align:left;" cellpadding="2" cellspacing="0" border="0" bgcolor="#FFFFFF">
<tr>
<td style="" colspan="2">
<font face="Verdana" size="2" color="#000000"><br />
<label style="font-size:15px;">Please fill in the following details to subscribe to our newsletter.<br /></label><br /></font>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Name</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<table cellpadding='0' cellspacing='0' border='0'>
<tr>
<td align='center' style='padding-left:0;padding-right:3px;'>
<input style='width:60px;' value='' id='element_0_2' name='element_0[]' type='text' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">First</font>
</td>
<td align='center' style='padding-left:0;'>
<input style='width:100px;' value='' id='element_0_3' name='element_0[]' type='text' class='validate[required]' /><br />
<font face="Verdana" size="2" color="#000000">Last</font>
</td>
</tr>
</table>
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Email</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<input id="element_1" name="element_1" class="validate[required,custom[email]]" value="" size="30" type="text" />
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr valign="top">
<td style="" align="left">
<font face="Verdana" size="2" color="#000000"><b>Phone Number</b></font> <span style="color:red;"><small>*</small></span>
</td>
<td style="">
<input id="element_2" name="element_2" class="validate[required,length[10,11],custom[onlyNumber]]" value="" size="12" type="text" />
<div style="padding-bottom:8px;color:#000000;"></div>
</td>
</tr>
<tr>
<td colspan="2">
<table cellpadding="5" cellspacing="0" bgcolor="#E4F8E4" width="100%">
<tr bgcolor="#AAD6AA">
<td colspan="2">
<font color="#FFFFFF" face="Verdana" size="2"><b>Image Verification</b></font>
</td>
</tr>
<tr>
<td style="padding:2px; width:100px;">
<img id="captcha_image" src="http://www.emailmeform.com/builder/captcha/index/bbad17232b5b80986cf7b0069850090e" alt="captcha" name="captcha_image" />
</td>
<td valign="top">
<div>
<font color="#000000">Please enter the text from the image</font>:<br />
<input type="text" id="captcha_code" name="captcha_code" maxlength="10" size="10" class="validate[required,funcCall[valid_captcha]]" /> [<a id="captcha_code_refresh" href=
"javascript:void(0);" onclick="document.getElementById('captcha_image').src = 'http://www.emailmeform.com/builder/captcha/index/'+Math.random();get_valid_captcha();return false;"
name="captcha_code_refresh">Refresh Image</a>] [<a id="captcha_code_about" href="javascript:void(0);" onclick=
"window.open('http://www.emailmeform.com/captcha-instruction.html','_blank','width=400, height=500, left=' + (screen.width-450) + ', top=100');return false;" name=
"captcha_code_about">What's This?</a>]
</div>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="2" align="left"><input value="Submit" type="submit" />
</td>
</tr>
</table>
</form><script type="text/javascript">
//<![CDATA[
$('body').append('<br /><div><font face="Verdana" size="2" color="#000000">Powered by<\/font><span style="position: relative; padding-left: 3px; bottom: -5px;"><img src="http://www.emailmeform.com/builder/images/footer-logo.png" /><\/span><font face="Verdana" size="2" color="#000000">EMF <\/font><a style="text-decoration:none;" href="http://www.emailmeform.com" target="_blank"><font face="Verdana" size="2" color="#000000"><font face="Verdana" size="2" color="#000000">Web Forms Builder<\/font><\/font><\/a><\/div><font face="Verdana" size="2" color="#000000"><a style="line-height:20px;font-size:70%;text-decoration:none;" href="http://www.emailmeform.com/report-abuse.html?http://www.emailmeform.com/builder/form/QWaG6hXkLa091284ZcdPd" target="_blank">Report Abuse<\/a><\/font>')
//]]>
</script><script type="text/javascript">
//<![CDATA[
$(function(){
$("#emf-form").validationEngine({
validationEventTriggers:"blur",
scroll:false
});
$('.datepicker').datepicker({
showOn: 'button',
buttonImage: base_url+'images/calendar.png',
buttonImageOnly: true,
onSelect: function(dateText, inst) {
var selectedDate = new Date(dateText);
$('#'+inst.id+'year').val(selectedDate.getFullYear());
$('#'+inst.id+'year-mm').val(((selectedDate.getMonth()+1)>9)?(selectedDate.getMonth()+1):('0'+(selectedDate.getMonth()+1)));
$('#'+inst.id+'year-dd').val(selectedDate.getDate()>9?selectedDate.getDate():'0'+selectedDate.getDate());
$('.'+inst.id+'yearformError').remove();
$('.'+inst.id+'year-mmformError').remove();
$('.'+inst.id+'year-ddformError').remove();
},
changeMonth: true,
changeYear: true
});
if(document.getElementById('captcha_image')!=null){
get_valid_captcha();
}
if(document.getElementById('captcha_image')!=null){
var isSafari = (/Safari/.test(navigator.userAgent));
var firstTimeSession = 0;
function process_captcha(){
$('a#captcha_code_refresh').trigger('click');
get_valid_captcha();
}
function safari_submit_session_form() {
if (firstTimeSession == 0) {
firstTimeSession = 1;
$("#safari_sessionform").submit();
setTimeout('process_captcha()',2000);
}
}
if(isSafari){
$("body").append('<iframe id="safari_sessionframe" name="safari_sessionframe" onload="safari_submit_session_form();" src="http://www.emailmeform.com/get_safari_cookies.php" style="display:none;"><\/iframe><form id="safari_sessionform" enctype="application/x-www-form-urlencoded" action="http://www.emailmeform.com/get_safari_cookies.php" target="safari_sessionframe" action="post"><\/form>');
}
}
});
//]]>
</script>
</body>
</html>