smartform

gistfile1.txt

        
<div class='moonray_forms moonray_smart_form'>
<form action="https://forms.moon-ray.com/v2.4/form_processor.php?" id="moonray_forms_706" method="post" data-captcha="false">
<input type="hidden" name="uid" value="p2c6505f6" />
<input type="hidden" name="contact_id" id="contact_id_706" value="" />

<input type="hidden" id="afft_706" name="afft_" value="" />
<input type="hidden" id="aff_706" name="aff_" value="" />
<input type="hidden" id="sess_706" name="sess_" value="" />
<input type="hidden" id="ref_706" name="ref_" value="" />
<input type="hidden" id="own_706" name="own_" value="" />
<input type="hidden" name="smartform" value="1">
<fieldset >
<!-- EDITABLE PARTS BELOW -->
<div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_firstname" for="firstname">First Name<span class="moonray_required">*</span></label><input type="text" name="firstname" value="" class="moonray_input required text" size="30"/></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_lastname" for="lastname">Last Name<span class="moonray_required">*</span></label><input type="text" name="lastname" value="" class="moonray_input required text" size="30"/></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_email" for="email">E-Mail<span class="moonray_required">*</span></label><input type="text" name="email" value="" class="moonray_input required text" size="30"/></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_address" for="address">Address</label><input type="text" name="address" value="" class="moonray_input  text" size="30"/></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_address2" for="address2">Address 2</label><input type="text" name="address2" value="" class="moonray_input  text" size="30"/></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_city" for="city">City</label><input type="text" name="city" value="" class="moonray_input  text" size="30"/></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_state" for="state">State</label><select name="state" class="moonray_input "><option value=''></option><option value='AL'>Alabama</option><option value='AK'>Alaska</option><option value='AZ'>Arizona</option><option value='AR'>Arkansas</option><option value='CA'>California</option><option value='CO'>Colorado</option><option value='CT'>Connecticut</option><option value='DE'>Delaware</option><option value='DC'>D.C.</option><option value='FL'>Florida</option><option value='GA'>Georgia</option><option value='HI'>Hawaii</option><option value='ID'>Idaho</option><option value='IL'>Illinois</option><option value='IN'>Indiana</option><option value='IA'>Iowa</option><option value='KS'>Kansas</option><option value='KY'>Kentucky</option><option value='LA'>Louisiana</option><option value='ME'>Maine</option><option value='MD'>Maryland</option><option value='MA'>Massachusetts</option><option value='MI'>Michigan</option><option value='MN'>Minnesota</option><option value='MS'>Mississippi</option><option value='MO'>Missouri</option><option value='MT'>Montana</option><option value='NE'>Nebraska</option><option value='NV'>Nevada</option><option value='NH'>New Hampshire</option><option value='NM'>New Mexico</option><option value='NJ'>New Jersey</option><option value='NY'>New York</option><option value='NC'>North Carolina</option><option value='ND'>North Dakota</option><option value='OH'>Ohio</option><option value='OK'>Oklahoma</option><option value='OR'>Oregon</option><option value='PA'>Pennsylvania</option><option value='RI'>Rhode Island</option><option value='SC'>South Carolina</option><option value='SD'>South Dakota</option><option value='TN'>Tennessee</option><option value='TX'>Texas</option><option value='UT'>Utah</option><option value='VT'>Vermont</option><option value='VA'>Virginia</option><option value='WA'>Washington</option><option value='WV'>West Virginia</option><option value='WI'>Wisconsin</option><option value='WY'>Wyoming</option><option value='AB'>Alberta</option><option value='BC'>British Columbia</option><option value='MB'>Manitoba</option><option value='NB'>New Brunswick</option><option value='NL'>Newfoundland and Labrador</option><option value='NS'>Nova Scotia</option><option value='NT'>Northwest Territories</option><option value='NU'>Nunavut</option><option value='ON'>Ontario</option><option value='PE'>Prince Edward Island</option><option value='QC'>Quebec</option><option value='SK'>Saskatchewan</option><option value='YT'>Yukon</option><option value='ACT'>(AU) Australian Capital Territory</option><option value='NSW'>(AU) New South Wales</option><option value='VIC'>(AU) Victoria</option><option value='QLD'>(AU) Queensland</option><option value='AU_NT'>(AU) Northern Territory</option><option value='AU_WA'>(AU) Western Australia</option><option value='SA'>(AU) South Australia</option><option value='TAS'>(AU) Tasmania</option><option value='GP'>(AF) Gauteng</option><option value='WP'>(AF) Western Cape</option><option value='EC'>(AF) Eastern Cape</option><option value='KZN'>(AF) Kwa-Zulu Natal</option><option value='NW'>(AF) North West</option><option value='AF_NC'>(AF) Northern Cape</option><option value='MP'>(AF) Mpumulanga</option><option value='FS'>(AF) Free State</option><option value='_NOTLISTED_'>My State is not listed</option></select></div><div class="moonray_form_field_wrapper"><label class="moonray_fieldname mr_zip" for="zip">Zip Code</label><input type="text" name="zip" value="" class="moonray_input  text" size="30"/></div>

</fieldset>
<input type="submit" value="Update">
<!-- EDITABLE ENDS (DO NOT EDIT CONTENTS BELOW)-->
</form>

<link rel="stylesheet" type="text/css" href="https://forms.moon-ray.com/v2.4/include/minify/?g=moonrayCSS">
<script type="text/javascript" src="https://forms.moon-ray.com/v2.4/include/minify/?g=moonrayJS"></script>
<script type="text/javascript" src="https://forms.moon-ray.com/v2.4/include/scripts/moonrayJS/smartform_loader.js?rand=706"></script>
</div>