<form id="ccsfg" name="ccsfg" method="post" action="../CCSFG_0.0.6/signup/index.php">

<p>To join our mailing list, please complete the information below and click 'Join'.</p>

<!-- ########## Email Address ########## -->
<label for="EmailAddress">Email Address</label>
<input type="text" name="EmailAddress" value="<?php echo $_POST["ea"]; ?>" id="EmailAddress" /><br /><br />

<!-- ########## First Name ########## -->
<label for="FirstName">First Name</label>
<input type="text" name="FirstName" value="" id="FirstName" /><br /><br />

<!-- ########## Last Name ########## -->
<label for="LastName">Last Name</label>
<input type="text" name="LastName" value="" id="LastName" /><br /><br />

<!-- ########## Zip/Postal Code ########## -->
<label for="PostalCode">Zip/Postal Code</label>
<input type="text" name="PostalCode" value="" id="PostalCode" /><br /><br />

<!-- ########## Are you currently a card carrying member? ########## -->
<label for="CustomField1">Are you currently a card carrying member?</label>
<input type="text" name="CustomField1" value="" id="CustomField1" /><br />

<!-- ########## Contact Lists ########## -->
<h5>Your Interests</h5>
<p>Let us know what kinds of emails you would like to receive from us.</p>

<input type="checkbox" checked="checked" value="News" name="Lists[]" id="list_News" />
<label class="inline-right" for="list_News">News</label><br />

<input type="checkbox" value="Youth" name="Lists[]" id="list_Youth" />
<label class="inline-right" for="list_Youth">Youth</label><br />

<input type="checkbox" value="Volunteering" name="Lists[]" id="list_Volunteering" />
<label class="inline-right" for="list_Volunteering">Volunteering</label><br />

<input type="checkbox" value="Action Alerts" name="Lists[]" id="list_Action Alerts" />
<label class="inline-right" for="list_Action Alerts">Action Alerts</label><br />

<!-- ########## Success / Failure Redirects ########## -->
<input type="hidden" name="SuccessURL" value="http://aclu-wi.org/node/1418" />
<input type="hidden" name="FailureURL" value="http://aclu-wi.org/node/1420" />

<input type="submit" name="signup" id="signup" value="Join" />

</form>