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Personal Web Pages - Sample Form


<form action="/cgi-bin/mailback.pl" method="POST">

<p>Please fill in the following information:</p>

<p>Customer's Name: <input type="text" name="CustomerName" size="60"></p>
<p>Street Address: <input type="text" name="StreetAddr" size="40"></p>
<p>City, Province: <input type="text" name="City" size="40"></p>
<p><textarea rows=7 cols=40 name="Notes"></textarea></p>

<input type="hidden" name="namefrom" value="Your Name">
<input type="hidden" name="mailfrom" value="email@couleedam.net">
<input type="hidden" name="mailitto" value="email@couleedam.net">
<input type="hidden" name="subject" value="Sample Form">

<input type="hidden" name="showreport">

<input type="hidden" name="returnmessage" value="Message sent!">
<input type="hidden" name="returnurl" value="couleedam.couleedam.net">
<input type="hidden" name="returngraphic" value="couleedam.couleedam.net/image.jpg">

<input type="Submit" name="submit" value="Submit" align="TOP">
<input type="Reset">

</form>

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