sign up contactform

[text* domainname class:textfield1 watermark “Domain Name”]	[text* company class:textfield1 watermark “Company”]
[text* firstname class:textfield1 watermark “First Name”]	[text* lastname class:textfield1 watermark “Last Name”]
[text* email class:textfield1 watermark “Email”]	[text phone class:textfield1 watermark “Phone”]
[checkbox* checkbox-196 “My customers are within 50 miles”]
[submit id:Submit class:submitbutton “Submit”]