PBT PROGRAMS

NEWS LETTER SIGN UP FORM

<style>
.link,
.link a,
.signupframe
{
color: #226699;
font-family: Arial, Helvetica, sans-serif;
font-size: 13px;
}
.link,
.link a {
text-decoration: none;
}
.signupframe {
border: 1px solid #000000;
background: #ffffff;
}
.signupframe .required {
font-size: 10px;
}
</style>
<form method="post" action="https://app.icontact.com/icp/signup.php" name="icpsignup" id="icpsignup4995" accept-charset="UTF-8" onsubmit="return verifyRequired4995();" >
<input type="hidden" name="redirect" value="http://www.icontact.com/www/signup/thanks.html">
<input type="hidden" name="errorredirect" value="http://www.icontact.com/www/signup/error.html">
 
<div id="SignUp">
<table width="260" class="signupframe" border="0" cellspacing="0" cellpadding="5">
<tr>
      <td valign="top" align="right">
        <span class="required">*</span> Email
      </td>
      <td align="left">
        <input type="text" name="fields_email">
      </td>
    </tr>
<tr>
      <td valign="top" align="right">
         First Name
      </td>
      <td align="left">
        <input type="text" name="fields_fname">
      </td>
    </tr>
<tr>
      <td valign="top" align="right">
         Last Name
      </td>
      <td align="left">
        <input type="text" name="fields_lname">
      </td>
    </tr>
<tr>
      <td valign="top" align="right">
         Phone
      </td>
      <td align="left">
        <input type="text" name="fields_phone">
      </td>
    </tr>
    <input type="hidden" name="listid" value="19246">
    <input type="hidden" name="specialid:19246" value="7I16">
 
    <input type="hidden" name="clientid" value="863751">
    <input type="hidden" name="formid" value="4995">
    <input type="hidden" name="reallistid" value="1">
    <input type="hidden" name="doubleopt" value="1">
    <tr>
      <td> </td>
      <td><span class="required">*</span> = Required Field</td>
    </tr>
    <tr>
      <td> </td>
      <td><input type="submit" name="Submit" value="Submit"></td>
    </tr>
    </table>
</div>
</form>
<script type="text/javascript">
 
var icpForm4995 = document.getElementById('icpsignup4995');
 
if (document.location.protocol === "https:")
 
icpForm4995.action = "https://app.icontact.com/icp/signup.php";
function verifyRequired4995() {
  if (icpForm4995["fields_email"].value == "") {
    icpForm4995["fields_email"].focus();
    alert("The Email field is required.");
    return false;
  }
 
 
return true;
}
</script>
<span class="link"><a href="http://www.icontact.com">Email Marketing</a> You Can Trust</span>
* Email
 First Name
 Last Name
 Phone
  * = Required Field
 

Email Marketing You Can Trust


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