HEX

File: //var/www/html/brokeronboard/index=2.html
<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8">
  <title>KRISUMI Lead Form</title>
  <meta http-equiv="Content-type" content="text/html; charset=UTF-8">
  <style>
    body {
      font-family: 'Segoe UI', sans-serif;
      background: linear-gradient(to right, #e0f7fa, #f1f8e9);
      margin: 0;
      padding: 40px;
    }

    .form-container {
      background-color: #ffffff;
      max-width: 600px;
      margin: auto;
      padding: 30px 30px 40px;
      border-radius: 12px;
      box-shadow: 0 10px 20px rgba(0,0,0,0.15);
    }

    .logo {
      display: block;
      max-width: 140px;
      height: auto;
      margin: 0 auto 20px auto;
    }

    .form-container h2 {
      text-align: center;
      color: #1a237e;
      margin-bottom: 25px;
    }

    form label {
      display: block;
      margin-bottom: 6px;
      font-weight: bold;
      color: #333;
    }

    form input[type="text"],
    form select,
    form textarea {
      width: 100%;
      padding: 10px;
      margin-bottom: 20px;
      border: 1px solid #b0bec5;
      border-radius: 5px;
      background-color: #f9f9f9;
      font-size: 14px;
    }

    form textarea {
      resize: vertical;
      height: 80px;
    }

    form input[type="submit"] {
      background-color: #1a73e8;
      color: #fff;
      border: none;
      border-radius: 6px;
      padding: 12px;
      font-size: 16px;
      cursor: pointer;
      width: 100%;
    }

    form input[type="submit"]:hover {
      background-color: #0c47a1;
    }
  </style>
</head>
<body>

<div class="form-container">
  <img src="https://krisumi.com/wp-content/uploads/2023/07/logo.png" alt="KRISUMI Logo" class="logo">

  <h2>KRISUMI - Broker Onboarding Form</h2>
  <form action="https://webto.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8&orgId=00D2w000008WWIC" method="POST">
    <input type="hidden" name="oid" value="00D2w000008WWIC">
    <input type="hidden" name="retURL" value="https://krisumi.com/">

    <label for="first_name">First Name</label>
    <input id="first_name" maxlength="40" name="first_name" type="text" />

    <label for="last_name">Last Name</label>
    <input id="last_name" maxlength="80" name="last_name" type="text" />

    <label for="email">Email</label>
    <input id="email" maxlength="80" name="email" type="text" />

    <label for="mobile">Mobile</label>
    <input id="mobile" maxlength="40" name="mobile" type="text" />

    <label for="company">Firm Name</label>
    <input id="company" maxlength="40" name="company" type="text" />

    <label for="00N2w00000BJeQS">GST</label>
    <input id="00N2w00000BJeQS" maxlength="50" name="00N2w00000BJeQS" type="text" />

    <label for="00N2w00000BJeV8">PAN No</label>
    <input id="00N2w00000BJeV8" maxlength="50" name="00N2w00000BJeV8" type="text" />

    <label for="00NIg000000LaGi">RERA Registered</label>
    <select id="00NIg000000LaGi" name="00NIg000000LaGi" title="RERA Registered">
      <option value="">--None--</option>
      <option value="Yes">Yes</option>
      <option value="No">No</option>
    </select>

    <label for="00NIg000000LZ55">RERA Registration No.</label>
    <textarea id="00NIg000000LZ55" name="00NIg000000LZ55"></textarea>

    <input type="submit" name="submit" value="Submit">
  </form>
</div>

</body>
</html>