<form action="http://email.marketing360.com/t/d/s/cjuiul/" method="post" id="subForm">
<p>
<label for="fieldName">Name</label><br />
<input id="fieldName" name="cm-name" type="text" />
</p>
<p>
<label for="fieldEmail">Email</label><br />
<input id="fieldEmail" name="cm-cjuiul-cjuiul" type="email" required />
</p>
<p>
<label for="fieldnuysl">Phone</label><br />
<input id="fieldnuysl" name="cm-f-nuysl" type="text" />
</p>
<p>
<label for="fieldnuysr">Company</label><br />
<input id="fieldnuysr" name="cm-f-nuysr" type="text" />
</p>
<p>
<label for="fieldnuysd">What is the MAIN intention for your tea sourcing?</label><br />
<select id="fieldnuysd" name="cm-fo-nuysd">
<option value=""></option>
<option value="1908461">Expand tea range</option>
<option value="1908462">Replace current supplier</option>
<option value="1908463">Find tea supplier for new cafe &#x2F; restaurant</option>
</select>
</p>
<p>
<label for="fieldnuysh">My tea business is located in -</label><br />
<select id="fieldnuysh" name="cm-fo-nuysh">
<option value=""></option>
<option value="1908464">Australia</option>
<option value="1908465">US and Canada</option>
<option value="1908466">Asia</option>
<option value="1908467">New Zealand &#x2F; Pacific Islands</option>
<option value="1908468">Other</option>
</select>
</p>
<p>
<label for="fieldnuygt">Select Primary Business</label><br />
<select id="fieldnuygt" name="cm-fo-nuygt">
<option value=""></option>
<option value="1908469">Tea Business (Online&#x2F;Offline)</option>
<option value="1908470">Cafe &amp; Restaurant</option>
<option value="1908471">Salon &amp; Spa</option>
</select>
</p>
<p>
<button type="submit">Subscribe</button>
</p>
</form>
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