<!-- ---------------------------------------------------------------------- --> <!-- 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="701360000000xxa" /> <input type="hidden" id="member_status" name="member_status" value=“EBN Campaign“ /><br> <input type=“hidden” id="00N3600000Bmi9b" maxlength="255" name="00N3600000Bmi9b" value="EBN Campaign"/><br> <input type=“hidden” id="lead_source" name="lead_source" value="EBN Campaign" /><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="phil.almeida@ebsbenefits.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="title">Title</label><input id="title" maxlength="40" name="title" size="20" type="text" /><br> <label for="phone">Phone</label><input id="phone" maxlength="40" name="phone" size="20" type="text" /><br> <label for="email">Email</label><input id="email" maxlength="80" name="email" size="20" type="text" /><br> <label for="employees">Employees</label><input id="employees" name="employees" size="20" type="text" value="" /><br> <label for="state">State/Province</label><input id="state" maxlength="20" name="state" size="20" type="text" /><br> <input type="submit" name="submit"> </form>