<form id=”myform” action=”https://forms.na1.netsuite.com/app/site/crm/externalleadpage.nl?compid=TSTDRV1184964&formid=25&h=57bc2a41b72dc0e0b5ed” method=”post”><!-- [et_pb_line_break_holder] --><label>First name</label><input name=”firstname” type=”text”><br><!-- [et_pb_line_break_holder] --><label>Last name</label><input name=”lastname” type=”text”><br><!-- [et_pb_line_break_holder] --><label>Email</label><input name=”email” type=”email”><br><!-- [et_pb_line_break_holder] --><label>Company name</label><input name=”companyname” type=”text”><br><!-- [et_pb_line_break_holder] --><label>Industry Type</label><!-- [et_pb_line_break_holder] --><select name=”custentity_industry_type”><!-- [et_pb_line_break_holder] --><option selected=”” value=””></option><!-- [et_pb_line_break_holder] --><option value=”4″>Computers, Peripherals, and Software</option><!-- [et_pb_line_break_holder] --><option value=”6″>Drugs, Proprietaries, and Sundries</option><!-- [et_pb_line_break_holder] --><option value=”8″>Electronic Parts and Equipment</option><!-- [et_pb_line_break_holder] --><option value=”11″>Furniture</option><!-- [et_pb_line_break_holder] --><option value=”10″>Hardware</option><!-- [et_pb_line_break_holder] --><option value=”5″>Industrial Machinery and Equipment</option><!-- [et_pb_line_break_holder] --><option value=”3″>Medical and Hospital Equipment</option><!-- [et_pb_line_break_holder] --><option value=”9″>Office Equipment</option><!-- [et_pb_line_break_holder] --><option value=”2″>Ophthalmic Goods</option><!-- [et_pb_line_break_holder] --><option value=”14″>Outdoor</option><!-- [et_pb_line_break_holder] --><option value=”12″>Photographic Equipment and Supplies</option><!-- [et_pb_line_break_holder] --><option value=”13″>Professional Equipment</option><!-- [et_pb_line_break_holder] --><option value=”7″>Sporting and Recreation Goods</option><!-- [et_pb_line_break_holder] --><option value=”1″>Wine and Distilled Beverages</option><!-- [et_pb_line_break_holder] --></select><!-- [et_pb_line_break_holder] --><div class=”comments”><label>Your comments</label><textarea name=”comments”></textarea></div><br><!-- [et_pb_line_break_holder] --><input type=”submit” value=”submit”><!-- [et_pb_line_break_holder] --></form>