<!-- ---------------------------------------------------------------------- --> <!-- NOTE: Please add the following <META> element to your page <HEAD>. --> <!-- If necessary, please modify the charset parameter to specify the --> <!-- character set of your HTML page. --> <!-- ---------------------------------------------------------------------- --> <META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8"> <!-- ---------------------------------------------------------------------- --> <!-- NOTE: Please add the following <FORM> element to your page. --> <!-- ---------------------------------------------------------------------- --> <form action="https://www.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST"> <input type=hidden name="oid" value="00D36000000JKKe"> <input type=hidden name="retURL" value="http://"> <input type="hidden" id="Campaign_ID" name="Campaign_ID" value="701360000000xE5" /> <input type="hidden" id="member_status" name="member_status" value=“Requested Demo“ /><br> <input type=“hidden†id="00N3600000Bmi9b" maxlength="255" name="00N3600000Bmi9b" value="Request a Demo"/><br> <input type=“hidden†id="lead_source" name="lead_source" value="WORKTERRA: W2L" /><br> <!-- ---------------------------------------------------------------------- --> <!-- NOTE: These fields are optional debugging elements. Please uncomment --> <!-- these lines if you wish to test in debug mode. --> <!-- <input type="hidden" name="debug" value=1> --> <!-- <input type="hidden" name="debugEmail" value="karen@akacrm.com"> --> <!-- ---------------------------------------------------------------------- --> <label for="first_name">First Name</label><input id="first_name" maxlength="40" name="first_name" size="20" type="text" /><br> <label for="last_name">Last Name</label><input id="last_name" maxlength="80" name="last_name" size="20" type="text" /><br> <label for="company">Company</label><input id="company" maxlength="40" name="company" size="20" type="text" /><br> <label for="email">Email</label><input id="email" maxlength="80" name="email" size="20" type="text" /><br> <label for="phone">Phone</label><input id="phone" maxlength="40" name="phone" size="20" type="text" /><br> <label for="country">Country</label><input id="country" maxlength="40" name="country" size="20" type="text" /><br> <label for="state">State/Province</label><input id="state" maxlength="20" name="state" size="20" type="text" /><br> <label for="city">City</label><input id="city" maxlength="40" name="city" size="20" type="text" /><br> Employee Range:<select id="00N36000007OJjx" name="00N36000007OJjx" title="Employee Range"><option value="">--None--</option><option value="Less than 50 Employees">Less than 50 Employees</option> <option value="50 - 500 Employees">50 - 500 Employees</option> <option value="501 - 1,000 Employees">501 - 1,000 Employees</option> <option value="1,001 - 2,500 Employees">1,001 - 2,500 Employees</option> <option value="2,501 - 5,000 Employees">2,501 - 5,000 Employees</option> <option value="5,001 - 10,000 Employees">5,001 - 10,000 Employees</option> <option value="10,001 - 25,000 Employees">10,001 - 25,000 Employees</option> <option value="> 25,000 Employees">> 25,000 Employees</option> </select><br> Interests:<select id="00N3600000Bk7HV" multiple="multiple" name="00N3600000Bk7HV" title="Interests"><option value="Recruit">Recruit</option> <option value="OnBoard">OnBoard</option> <option value="BenAdmin">BenAdmin</option> <option value="Exchange">Exchange</option> <option value="Wellness">Wellness</option> <option value="ACA Compliance">ACA Compliance</option> </select><br> Web to Lead Comments / Questions:<textarea id="00N3600000Bk7X6" name="00N3600000Bk7X6" rows="5" type="text" wrap="soft"></textarea><br> <input type="submit" name="submit"> </form>