<?xml version="1.0" encoding="UTF-8"?>

<form url="personalfactors.php"
 window="_self"
 method="POST"
 fontname="MS Sans Serif"
 width="400"
 height="650"
 bkcolor="0xF8EDD1"
 transparent="f"
 fontcolor="0x000000"
 outlinecolor="0x070300"
 themecolor="0xFFFF99"
 fontcolor2="#000000"
 bkcolor2="#FFFFFF"
 includeresults="false"
 emailuser="false"
 verifymessage="The E-Mail Address you entered does not match!"
 reqmessage="One or more fields are required."
 invalidemailmsg="The E-Mail Address does not appear to be a valid e-mail address. Would you like to change it?"
 transition="0"
 autoresponseincluderesults="f"
 autoresponseaddtotop="f"
 usephp="true"
disableclicktoactiveprompt="false"
 extensions="*.txt;*.gif;*.jpg;*.jpeg;*.zip;*.doc;*.png;*.pdf;*.rtf;*.html;*.docx;*.xslx"
>

<hidden
 name="thankyoupage"
 value="http://www.dynamic-life-coaching.com/appreciation.html"
></hidden>

<hidden
 name="subject"
 value=""
></hidden>

<textinput
 name="Name"
 x="25"
 y="100"
 w="200"
 h="22"
 initvalue=""
 maxchars="30"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
>
</textinput>

<textinput
 name="E-Mail"
 x="25"
 y="175"
 w="199"
 h="22"
 initvalue=""
 maxchars="35"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 emailbox="true"
 editable="true"
  restrict="email"
>
</textinput>

<textinput
 name="E-Mail Confirm"
 x="25"
 y="250"
 w="199"
 h="22"
 initvalue=""
 maxchars="35"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
 emailvalidatebox="true"
>
</textinput>

<textinput
 name="Telephone"
 x="25"
 y="325"
 w="175"
 h="22"
 initvalue=""
 maxchars="20"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
>
</textinput>

<textinput
 name="City"
 x="25"
 y="400"
 w="201"
 h="22"
 initvalue=""
 maxchars="20"
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 required="true"
 editable="true"
>
</textinput>

<captcha
 name="My Captcha 1"
 x="125"
 y="450"
 w="133"
 h="100"
 text="Enter Code Here:"
 fnt="Verdana"
 fntclr="0x000000"
 fntsize="13"
 bkbdrcolor="0x1D0100"
 bkfillclr="0xFFFFFF"
 bkdobdr="t"
 bkbdrsolid="t"
 bkdobk="t"
 bkfillalpha="100"
 message="Incorrect Code"
></captcha>

<submitbutton
 name="Submit Button"
 x="150"
 y="575"
 w="92"
 h="26"
 label="Submit"
 fontname="Verdana"
 fontcolor="0x000000"
 fontbold="bold"
  fontsize="16"
></submitbutton>

<label
 name="My Text 1"
 x="100"
 y="0"
 w="186"
 h="29"
 text="Find Out Now"
 fontbold="bold"
  fontname="Verdana"
  fontcolor="0x070300"
  fontsize="23"
></label>

<label
 name="My Text 2"
 x="25"
 y="75"
 w="116"
 h="16"
 text="Name &amp; Surname"
  fontname="Verdana"
  fontcolor="0x070300"
  fontsize="13"
></label>

<label
 name="My Text 3"
 x="25"
 y="150"
 w="44"
 h="16"
 text="E-Mail"
  fontname="Verdana"
  fontcolor="0x070300"
  fontsize="13"
></label>

<label
 name="My Text 4"
 x="25"
 y="300"
 w="126"
 h="16"
 text="Telephone Number"
  fontname="Verdana"
  fontcolor="0x070300"
  fontsize="13"
></label>

<label
 name="My Text 5"
 x="25"
 y="375"
 w="72"
 h="16"
 text="City/Town"
  fontname="Verdana"
  fontcolor="0x070300"
  fontsize="13"
></label>

<label
 name="My Text 7"
 x="25"
 y="225"
 w="98"
 h="16"
 text="Confirm E-Mail"
  fontname="Verdana"
  fontcolor="0x070300"
  fontsize="13"
></label>

</form>
