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<form enctype="multipart/form-data" method="post" action="http://www.freedback.com/mail.php" accept-charset="UTF-8">

<div>

<input type="hidden" name="acctid" id="acctid" value="8assjmp2xnhfzwp6" />

<input type="hidden" name="formid" id="formid" value="169643" />

<input type="hidden" name="required_vars" id="required_vars" value="field-bf1efeba3dce485,field-cb5ef0a28cb22ff,field-b14c0de76ccee86,field-9f5f2f16a20f5b7,field-2243ca3068a95c1" />

</div>

<table cellspacing="5" cellpadding="5" border="0">

<tr>

<td valign="top">

<strong>Company name</strong>

</td>

<td valign="top">

<input type="text" name="field-bf1efeba3dce485" id="field-bf1efeba3dce485" size="40" value="" />

</td>

</tr>

<tr>

<td valign="top">

<strong>Contact Name</strong>

</td>

<td valign="top">

<input type="text" name="field-cb5ef0a28cb22ff" id="field-cb5ef0a28cb22ff" size="40" value="" />

</td>

</tr>

<tr>

<td valign="top">

<strong>Your Email Address</strong>

</td>

<td valign="top">

<input type="text" name="field-b14c0de76ccee86" id="field-b14c0de76ccee86" size="40" value="" />

</td>

</tr>

<tr>

<td valign="top">

<strong>Telephone / Extension</strong>

</td>

<td valign="top">

<input type="text" name="field-9f5f2f16a20f5b7" id="field-9f5f2f16a20f5b7" size="40" value="" />

</td>

</tr>

<tr>

<td valign="top">

<strong>How can we help you ?</strong>

</td>

<td valign="top">

<textarea name="field-2243ca3068a95c1" id="field-2243ca3068a95c1" rows="6" cols="40"></textarea>

</td>

</tr>

<tr>

<td colspan="2" align="center">

<input type="submit" value=" Submit Form " />

</td>

</tr>

</table>

</form>

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