HMS Pembelian Online

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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="wa64fuy8iqbk84ip" />
  <input type="hidden" name="formid" id="formid" value="925562" />
  <input type="hidden" name="required_vars" id="required_vars" value="name,email,field-4748a59abb12ef6" />
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 <table cellspacing="5" cellpadding="5" border="0">
  <tr>
   <td valign="top">
    <strong>Nama/Name:</strong>
   </td>
   <td valign="top">
    <input type="text" name="name" id="name" size="40" value="" />

   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>Emel/Email:</strong>
   </td>
   <td valign="top">
    <input type="text" name="email" id="email" size="40" value="" />

   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>Tel./Phone no:</strong>
   </td>
   <td valign="top">
    <input type="text" name="field-4748a59abb12ef6" id="field-4748a59abb12ef6" size="40" value="" />

   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>Alamat/Address:</strong>
   </td>
   <td valign="top">
    <textarea name="field-65b9da7ca80c26f" id="field-65b9da7ca80c26f" rows="6" cols="40"></textarea>

   </td>
  </tr>
  <tr>
   <td valign="top">
    <strong>Pertanyaan/Questions:</strong>
   </td>
   <td valign="top">
    <textarea name="field-facb50abe2a91cc" id="field-facb50abe2a91cc" 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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