<html>
<head>
<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="stylesheet" href= "style.css">
<script src="https://www.google.com/recaptcha/api.js"></script>
<script>
function timestamp() { var response = document.getElementById("g-recaptcha-response"); if (response == null || response.value.trim() == "") {var elems = JSON.parse(document.getElementsByName("captcha_settings")[0].value);elems["ts"] = JSON.stringify(new Date().getTime());document.getElementsByName("captcha_settings")[0].value = JSON.stringify(elems); } } setInterval(timestamp, 500);
</script>
</head>
<body>
<div class="container">
<form action="https://webto.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST">
<input type=hidden name='captcha_settings' value='{"keyname":"MIDIS_WEB_TO_LEAD","fallback":"true","orgId":"00D24000000JNoY","ts":""}'>
<input type=hidden name="oid" value="00D24000000JNoY">
<input type=hidden name="recordType" value="01224000000LRRq">
<input type=hidden name="00N1o00000Jsr1R" value="-">
<input type=hidden name="retURL" value="https://abc.com.qa/">
<div class="row">
<div class="col-50">
<label for="salutation">Salutation</label>
<select class="" id="salutation" name="salutation" required>
<option value="">--None--</option>
<option value="Mr.">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mrs.">Mrs.</option>
<option value="Dr.">Dr.</option>
<option value="Prof.">Prof.</option>
</select>
</div>
</div>
<div class="row">
<div class="col-50">
<label for="first_name">First Name</label>
<input class="" placeholder="First Name" id="first_name" maxlength="40" name="first_name" size="20" type="text" required />
</div>
<div class="col-50">
<label for="last_name">Last Name</label>
<input class="" placeholder="Last Name" id="last_name" maxlength="80" name="last_name" size="20" type="text" required /><br>
</div>
</div>
<div class="row">
<div class="col-50">
<label for="company">Company</label>
<input class="" placeholder="Company" id="company" maxlength="40" name="company" size="20" type="text" required />
</div>
<div class="col-50">
<label for="phone">Phone Number</label>
<input class="" placeholder="Phone No" id="phone" maxlength="40" name="phone" size="20" type="text" required /><br>
</div>
</div>
<div class="row">
<div class="col-50">
<label for="email">Work mail</label>
<input class="" placeholder="Email" id="email" maxlength="80" name="email" size="20" type="text" required /><br>
</div>
</div>
<div class="row">
<div class="col-100">
Kindly identify your area of interest?
<select id="00N0E00000HLPfA" name="00N0E00000HLPfA" title="Area of interest" required>
<option value="">--None--</option>
<option value="Job Opportunities">Job Opportunities</option>
<option value="Solutions/Services">Solutions/Services</option>
<option value="Vendor Partnership">Vendor Partnership</option>
</select>
</div>
</div>
<div class="row">
<div class="col-50">
<label for="lead_source">How did you hear about us?</label>
<select class="" id="lead_source" name="lead_source" required>
<option value="">--None--</option>
<option value="Advertisements / Marketing Campaigns">Advertisements / Marketing Campaigns</option>
<option value="Events and Conferences">Events and Conferences</option>
<option value="Magazines / Publications">Magazines / Publications</option>
<option value="Referrals / Word-of-mouth">Referrals / Word-of-mouth</option>
<option value="Telemarketing">Telemarketing</option>
<option value="Web search (Google, Yahoo, etc)">Web search (Google, Yahoo, etc)</option>
<option value="Social Media (LinkedIn, Facebook, etc.)">Social Media (LinkedIn, Facebook, etc.)</option>
</select>
</div>
</div>
<div class="row">
<div class="col-100">
<label for="description">Your Message</label>
<textarea name="description"></textarea>
</div>
</div>
<div class="row">
<div class="col-100">
<div class="g-recaptcha" data-sitekey="6Lc3-XAgAAAAABNwgtCyKGNx9gNM0n9pqdL1C4Lk"></div><br>
<input type="submit" name="submit">
</div>
</div>
</form>
</div>
</body>
</html>
