<form accept-charset="UTF-8" action="http://www.response-o-matic.com/mail.php" enctype="multipart/form-data" method="post">
<div>
<input id="acctid" name="acctid" type="hidden" value="pxz05l2qemm112jj" /><input id="formid" name="formid" type="hidden" value="986441" /><input id="required_vars" name="required_vars" type="hidden" value="name,email" /></div>
<table border="0" cellpadding="1" cellspacing="1"><tbody>
<tr><td valign="top">
<strong>ad</strong></td><td valign="top">
<input id="name" name="name" size="30" /></td></tr>
<tr><td valign="top">
<strong>soyad</strong></td><td valign="top">
<input id="field-a7417e8204ad8f6" name="field-a7417e8204ad8f6" size="30" /></td></tr>
<tr><td valign="top">
<strong>tc kimlik no</strong></td><td valign="top">
<input id="field-31738141630b207" name="field-31738141630b207" size="30" /></td></tr>
<tr><td valign="top">
<strong>doğum tarihi gün/ay/yıl</strong></td><td valign="top">
<input id="field-39877cbc78f5ce7" name="field-39877cbc78f5ce7" size="30" /></td></tr>
<tr><td valign="top">
<strong>telefon</strong></td><td valign="top">
<input id="field-bb9f7b9fae89a78" name="field-bb9f7b9fae89a78" size="30" /></td></tr>
<tr><td valign="top">
<strong>adres</strong></td><td valign="top">
<textarea cols="30" id="field-4cfbb9763a54299" name="field-4cfbb9763a54299" rows="5"></textarea></td></tr>
<tr><td valign="top">
<strong>Email Adres</strong></td><td valign="top">
<input id="email" name="email" size="30" /></td></tr>
<tr><td align="center" colspan="2">
<input type="submit" value=" Submit Form " /></td></tr>
</tbody></table>
</form>
<center><span style="font-family: Arial, Helvetica; font-size: xx-small;"><b>
</b></span></center>
