Secondary - [#192550]

wave_lg

wave-md

Primary Lightest - [#ABF7E8]

<form action="https://simplycorporate.my.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8"
  id="interestedInJoining" method="POST" class="needs-validation custom-form">
  <div class="hidden-fields">
    
    
    
    <input type="hidden" name="oid" value="00Db0000000HCeX" />
    <input type="hidden" name="retURL" id="retURL" />
    <input type="hidden" name="recordType" id="recordType" value="0123z000000YWIc" />
    <input type="hidden" name="lead_source" id="lead_source" value="Web - Request Callback" />
    <input type="hidden" name="rating" id="rating" value="Hot" />
    <input type="hidden" name="status" value="New" />
  </div>

  <div class="form-group">
    <label for="first_name">First name<sup title="required">*</sup></label>
    <input type="text" id="first_name" name="first_name" class="form-control" maxlength="40" size="20"
      placeholder="e.g. John" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="last_name">Last name<sup title="required">*</sup></label>
    <input type="text" id="last_name" name="last_name" class="form-control" maxlength="80" size="20"
      placeholder="e.g. Smith" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="phone">Phone<sup title="required">*</sup></label>
    <input type="tel" id="phone" name="phone" class="form-control" maxlength="40" size="20"
      placeholder="e.g. 07400123456" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="Preferred_Call_Time__c">Your preferred call back time (optional)</label>
    <select name="Preferred_Call_Time__c" id="Preferred_Call_Time__c" aria-invalid="true">
      <option value="null">Please select</option>
      <option value="AM">Morning</option>
      <option value="PM">Afternoon</option>
      <option value="Evening">Evening</option>
      <option value="Weekend">Weekend</option>
    </select>
    <p>We will try and get back to you within your preferred time.</p>
  </div>
  <div class="form-group">
    <label for="email">Email<sup title="required">*</sup></label>
    <input type="text" name="email" id="email" class="form-control" maxlength="80" size="20" placeholder="Email address"
      aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="postcode">Postcode<sup title="required">*</sup></label>
    <input name="zip" id="postcode" class="form-control" maxlength="50" size="20" type="text" placeholder="Postcode"
      aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="Birthdate__c">Date of birth<sup title="required">*</sup></label>
    <input type="date" id="Birthdate__c" name="Birthdate__c" class="form-control js-date" maxlength="80" size="20"
      placeholder="DD/MM/YYYY" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="description">Comments (optional)</label>
    <textarea id="description" name="description" class="form-control" rows="5" cols="100"
      placeholder="Please provide more details"></textarea>
  </div>
  <div class="buttons">
    <button type="submit" id="formsubmit" name="submit" class="btn btn-tertiary">
      Submit
    </button>
  </div>
</form>

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