from a new perspective

<form method="post" action="http://lpctunb.entregadeemails.com/recebeForm.php">
<input type="hidden" name="uniqid" value="11191471842283788" />
<input type="hidden" name="senha" value="9e36f3e716d43afb90c7340d499b3ef4" />
<input type="hidden" name="id_sender_email" value="4024" />
<input type="hidden" name="urlredir" value="http://www.lpct.com.br" />
<table id="tabelaDados" cellspacing="0" >
<col style="width:35%" />
<tr>
<td >E-mail*</td>
<td ><input name="email" type="text" value="" /></td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td >
<h5>Mais informações</h5>
</td><tr id="row_DadosAvancados" >
<td colspan="2"> </td>
</tr><tr id="row_DadosAvancados" >
<td >Nome</td>
<td ><input name="nome" type="text" value="" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Sobrenome</td>
<td ><input type="text" name="attribute[2]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Data de Nascimento</td>
<td ><input type="hidden" name="dateattribute[3]" value="Data de Nascimento" /><input type=hidden name="Data de Nascimento" value="1"><select class="combo_estilo" id="day_Data de Nascimento" name="day[Data de Nascimento]" style="width:4em;"><option value=""></option>
<option value="01" >1</option>
<option value="02" >2</option>
<option value="03" >3</option>
<option value="04" >4</option>
<option value="05" >5</option>
<option value="06" >6</option>
<option value="07" >7</option>
<option value="08" >8</option>
<option value="09" >9</option>
<option value="10" >10</option>
<option value="11" >11</option>
<option value="12" >12</option>
<option value="13" >13</option>
<option value="14" >14</option>
<option value="15" >15</option>
<option value="16" >16</option>
<option value="17" >17</option>
<option value="18" >18</option>
<option value="19" >19</option>
<option value="20" >20</option>
<option value="21" >21</option>
<option value="22" >22</option>
<option value="23" >23</option>
<option value="24" >24</option>
<option value="25" >25</option>
<option value="26" >26</option>
<option value="27" >27</option>
<option value="28" >28</option>
<option value="29" >29</option>
<option value="30" >30</option>
<option value="31" selected>31</option>
</select>  <select class="combo_estilo" id="month_Data de Nascimento" name="month[Data de Nascimento]" style="width:9em;"><option value=""></option>
<option value="01" >Janeiro</option>
<option value="02" >Fevereiro</option>
<option value="03" >Março</option>
<option value="04" >Abril</option>
<option value="05" >Maio</option>
<option value="06" >Junho</option>
<option value="07" >Julho</option>
<option value="08" >Agosto</option>
<option value="09" >Setembro</option>
<option value="10" >Outubro</option>
<option value="11" >Novembro</option>
<option value="12" selected>Dezembro</option></select>  <input type=text name="year[Data de Nascimento]" size=4 maxlength=4 class="text2" value="1969"></td>
</tr><tr id="row_DadosAvancados" >
<td >Sexo</td>
<td ><select name="attribute[4]" style="attributeinput" ><option value="0">nenhum</option><option value="4" >Feminino</option><option value="3" >Masculino</option></select></td>
</tr><tr id="row_DadosAvancados" >
<td colspan="2"> </td>
</tr>
<tr id="row_DadosAvancados" >
<td ><h5>Dados Profissionais</h5></td></tr><tr id="row_DadosAvancados" >
<td colspan="2"> </td>
</tr><tr id="row_DadosAvancados" >
<td >Empresa</td>
<td ><input type="text" name="attribute[5]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Departamento</td>
<td ><input type="text" name="attribute[6]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Cargo</td>
<td ><input type="text" name="attribute[7]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td colspan="2"> </td>
</tr>
<tr id="row_DadosAvancados" >
<td ><h5>Endereço</h5></td></tr><tr id="row_DadosAvancados" >
<td colspan="2"> </td>
</tr><tr id="row_DadosAvancados" >
<td >Endereço</td>
<td ><input type="text" name="attribute[9]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Número</td>
<td ><input type="text" name="attribute[10]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Complemento</td>
<td ><input type="text" name="attribute[11]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Bairro</td>
<td ><input type="text" name="attribute[12]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Cidade</td>
<td ><input type="text" name="attribute[13]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Estado</td>
<td ><select name="attribute[14]" style="attributeinput" ><option value="0">nenhum</option><option value="1" >AC</option><option value="2" >AL</option><option value="3" >AM</option><option value="4" >AP</option><option value="5" >BA</option><option value="6" >CE</option><option value="7" >DF</option><option value="8" >ES</option><option value="9" >GO</option><option value="10" >MA</option><option value="11" >MG</option><option value="12" >MS</option><option value="13" >MT</option><option value="14" >PA</option><option value="15" >PB</option><option value="16" >PE</option><option value="17" >PI</option><option value="18" >PR</option><option value="19" >RJ</option><option value="20" >RN</option><option value="21" >RO</option><option value="22" >RR</option><option value="23" >RS</option><option value="24" >SC</option><option value="25" >SE</option><option value="26" >SP</option><option value="27" >TO</option></select></td>
</tr><tr id="row_DadosAvancados" >
<td >CEP</td>
<td ><input type="text" name="attribute[15]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Telefone Residencial</td>
<td ><input type="text" name="attribute[16]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Telefone Comercial</td>
<td ><input type="text" name="attribute[17]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Telefone Celular</td>
<td ><input type="text" name="attribute[18]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Fax</td>
<td ><input type="text" name="attribute[19]" value="" style="width: 98%" /></td>
</tr><tr id="row_DadosAvancados" >
<td >Anotações</td>
<td ><textarea name="attribute[20]" rows="6" cols="40" style="width: 98%"></textarea></td>
</tr></table> <input type="submit" value="enviar" />
</form>

from a new perspective

sexta-feira, 16 de agosto de 2013

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