| Linux hosting5.siteguarding.com 3.10.0-962.3.2.lve1.5.88.el7.x86_64 #1 SMP Fri Sep 26 14:06:42 UTC 2025 x86_64 Path : /home/devsafetybis/verd.dev.safetybis.com/securemailer/ |
| Current File : /home/devsafetybis/verd.dev.safetybis.com/securemailer/form.php |
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.1//EN" "http://www.w3.org/TR/xhtml11/DTD/xhtml11.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en">
<head>
<title>Contact Us</title>
<meta http-equiv="content-type" content="text/html; charset=utf-8"/>
<meta name="description" content="Contact us"/>
<meta name="keywords" content="contact, us"/>
</head>
<body>
<!-- base your form on this example when file uploads ARE NOT required -->
<div style="width:60%;margin-left:auto;margin-top:20px;margin-right:auto">
<form action="securemailer.php" method="post">
<table cellpadding="0" cellspacing="1" border="0" style="width:100%;border:1px solid #e3e3e3; font: 11px Tahoma">
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>Full Name</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="name" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>Email Address</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="email" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>Subject</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="subject" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>Address</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="address" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>City</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="city" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>County</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="state" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>Post Code</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="zipcode" size="30" style="border:1px solid #94A5B5;-moz-border-radius:4px;" /></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"> <b>Message</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><textarea name="message" rows="10" cols="29" style="border:1px solid #94A5B5;-moz-border-radius:4px;"></textarea></td>
</tr>
<tr>
<td valign="middle" style="width:30%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><b>Verifcation</b></td>
<td valign="middle" style="width:70%;background-color:#f1f1f1; border-right:1px solid white; padding:4px;"><input type="text" name="imageverify" size="30" /> <img src="image.php" alt="please enter the code exactly as displayed" /></td>
</tr>
</table>
<p>
<input type="submit" value="Submit" style="width:135px;height:21px;color:#003973;border:1px solid #94A5B5;-moz-border-radius:4px;font:11px Tahoma;padding-bottom:2px" /> <input type="reset" style="color:#003973; height:21px; width:38px;border:1px solid #94A5B5;-moz-border-radius:4px;font:11px Tahoma;padding-bottom:2px" />
</p>
</form>
</div>
</body>
</html>