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<form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="7n3hz3f78u8t8vxv" />
<input type="hidden" name="formid" id="formid" value="827406" />
<input type="hidden" name="required_vars" id="required_vars" value="name,email" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Name:</strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Nama FB</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>NO.IC</strong>
</td>
<td valign="top">
<input type="text" name="field-d451b94f3fc4fb2" id="field-d451b94f3fc4fb2" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>NO.TEL</strong>
</td>
<td valign="top">
<textarea name="field-ff2fe6312f2376e" id="field-ff2fe6312f2376e" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>JUMLAH PEMBAYARAN</strong>
</td>
<td valign="top">
<textarea name="field-9b63e4c2aa251e6" id="field-9b63e4c2aa251e6" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Transakasi Pembayaran</strong>
</td>
<td valign="top">
<textarea name="field-7c13ef9d0ecd56b" id="field-7c13ef9d0ecd56b" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Masa Transaksi</strong>
</td>
<td valign="top">
<input type="text" name="field-8a56cfa99d879a3" id="field-8a56cfa99d879a3" size="40" value="" />
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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