<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
< html>
< head>
< title>UniMailer Documentation &amp; Configuration</title>
< meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
< link href="https://unimailer.uniweb.be/assets/css/newUniStyle1.css" rel="stylesheet" type="text/css">
< /head>

<body>

<Form action="https://unimailer.uniweb.be/unimailer.php" METHOD=POST>
< input type=hidden name="recipient" value="pN7gBZq4SQ3tfdlrQBAibwuVYu6EkZWg+rRiGqlefuzSmVoNHZqTXHKQf1ZCwJerW+yx1XZZiBrsXp8rCzD5V/Ryuq1nPZlChnnNZ9H3+1Hw==">
< input type=hidden name="subject" value="Support Feedback">
< input type=hidden name="redirect" value="">
< input type=hidden name="require" value="Name,email,Telephone">
< input type=hidden name="title" value="Feedback form">
< input type=hidden name="missing_fields_redirect" value="">
< input type=hidden name="message1" value="Thank you for your submission !">
< input type=hidden name="message2" value="your email address is invalid">
< input type=hidden name="message3" value="The form was not submitted because the following(s) field(s) are incorrect or missing:">
< input type=hidden name="message4" value="Click here to return to the form and try again.">

<!-- Your form HTML code here -->

<table width="650" border="0" align="center" cellpadding="0" cellspacing="10">
<tr>
<td align="center" valign="middle" bgcolor="#dddddd"><div align="center"><span class="bluebold">Feedback
Form exemple</span></div></td>
</tr>
<tr>
<td valign="top" bgcolor="#eeeeee"><span class="bluebold"><br>
<br>
</span> <table width="70%" border="1" align="center" cellpadding="0" cellspacing="0" bordercolor="#dddddd">
<tr>
<td height="40" colspan="2"><div align="center">Please complete the form
below. ( * denotes mandatory field )</div></td>
</tr>
<tr>
<td width="38%">Name<font color="#FF0000">*</font></td>
<td width="62%"><font face="Arial" size="2">
<input type="text" name="Name" size="30" maxlength="100">
</font></td>
</tr>
<tr>
<td>Position</td>
<td><font face="Arial" size="2">
<input type="text" name="Position" size="30" maxlength="100">
</font></td>
</tr>
<tr>
<td>Street Address</td>
<td><font face="Arial" size="2">
<input type="text" name="Address" size="30" maxlength="100">
</font></td>
</tr>
<tr>
<td>City</td>
<td><font face="Arial" size="2">
<input type="text" name="City" size="30" maxlength="100">
</font></td>
</tr>
<tr>
<td>Zip</td>
<td><font face="Arial" size="2">
<input type="text" name="Zip" size="11" maxlength="10">
</font></td>
</tr>
<tr>
<td>Country</td>
<td><select name="Country" id="Country">
<option selected>Please choose a country
<option value="Afghanistan">Afghanistan
<option value="Albania">Albania
<option value="Algeria">Algeria
<option value="American_Samoa">American Samoa
<option value="Andorra">Andorra
<option value="Angola">Angola
<option value="Anguilla">Anguilla
<option value="Antarctica">Antarctica
<option value="Antigua_Barbuda">Antigua and Barbuda
<option value="Argentina">Argentina
<option value="Armenia">Armenia
<option value="Aruba">Aruba
<option value="Australia">Australia
<option value="Austria">Austria
<option value="Azerbaijan">Azerbaijan
<option value="Bahamas">Bahamas
<option value="Bahrain">Bahrain
<option value="Bangladesh">Bangladesh
<option value="Barbados">Barbados
<option value="Belarus">Belarus
<option value="Belgium">Belgium
<option value="Belize">Belize
<option value="Benin">Benin
<option value="Bermuda">Bermuda
<option value="Bhutan">Bhutan
<option value="Bolivia">Bolivia
<option value="Bosnia_Herzegovina">Bosnia and Herzegovina
<option value="Botswana">Botswana
<option value="Bouvet_Island">Bouvet Island
<option value="Brazil">Brazil
<option value="British_Indian_Ocean_Territory">British Indian Ocean Territory
<option value="Brunei_Darussalam">Brunei Darussalam
<option value="Bulgaria">Bulgaria
<option value="Burkina_Faso">Burkina Faso
<option value="Burundi">Burundi
<option value="Cambodia">Cambodia
<option value="Cameroon">Cameroon
<option value="Canada">Canada
<option value="Cape_Verde">Cape Verde
<option value="Cayman_Islands">Cayman Islands
<option value="Central_African_Republic">Central African Republic
<option value="Chad">Chad
<option value="Chile">Chile
<option value="China">China
<option value="Christmas_Island_Aus">Christmas Island (Australia)
<option value="Cocos_Islands">Cocos (Keeling) Islands
<option value="Colombia">Colombia
<option value="Comoros">Comoros
<option value="Congo">Congo
<option value="Congo_Dem_Rep">Congo, The Democratic Republic Of The
<option value="Cook_Islands">Cook Islands
<option value="Costa_Rica">Costa Rica
<option value="Ivory_Coast">Cote D'Ivoire (Ivory Coast)
<option value="Croatia">Croatia (Hrvatska)
<option value="Cuba">Cuba
<option value="Cyprus">Cyprus
<option value="Czech_Republic">Czech Republic
<option value="Denmark">Denmark
<option value="Djibouti">Djibouti
<option value="Dominica">Dominica
<option value="Dominican_Republic">Dominican Republic
<option value="East_Timor">East Timor
<option value="Ecuador">Ecuador
<option value="Egypt">Egypt
<option value="El_Salvador">El Salvador
<option value="Equatorial_Guinea">Equatorial Guinea
<option value="Eritrea">Eritrea
<option value="Estonia">Estonia
<option value="Ethiopia">Ethiopia
<option value="Faeroe_Islands">Faeroe Islands
<option value="Falkland_Islands">Falkland Islands (Malvinas)
<option value="Fiji">Fiji
<option value="Finland">Finland
<option value="France">France
<option value="France_Metropolitan">France, Metropolitan
<option value="French_Guiana">French Guiana
<option value="French_Polynesia">French Polynesia
<option value="French_Southern_Territories">French Southern Territories
<option value="Gabon">Gabon
<option value="Gambia">Gambia
<option value="Georgia">Georgia
<option value="Germany">Germany
<option value="Ghana">Ghana
<option value="Gibraltar">Gibraltar
<option value="Greece">Greece
<option value="Greenland">Greenland
<option value="Grenada">Grenada
<option value="Guadeloupe">Guadeloupe
<option value="Guam">Guam
<option value="Guatemala">Guatemala
<option value="Guinea">Guinea
<option value="Guinea_Bissau">Guinea Bissau
<option value="Guyana">Guyana
<option value="Haiti">Haiti
<option value="Heard_McDonald_Islands">Heard And McDonald Islands
<option value="Honduras">Honduras
<option value="Hong_Kong">Hong Kong
<option value="Hungary">Hungary
<option value="Iceland">Iceland
<option value="India">India
<option value="Indonesia">Indonesia
<option value="Iran">Iran
<option value="Iraq">Iraq
<option value="Ireland">Ireland
<option value="Israel">Israel
<option value="Italy">Italy
<option value="Jamaica">Jamaica
<option value="Japan">Japan
<option value="Jordan">Jordan
<option value="Kazakhstan">Kazakhstan
<option value="Kenya">Kenya
<option value="Kiribati">Kiribati
<option value="Korea_N">Korea (North)
<option value="Korea_S">Korea (South)
<option value="Kuwait">Kuwait
<option value="Kyrgyzstan">Kyrgyzstan
<option value="Lao_PDR">Lao P.Dem.R.
<option value="Latvia">Latvia
<option value="Lebanon">Lebanon
<option value="Lesotho">Lesotho
<option value="Liberia">Liberia
<option value="Libyan_Arab_Jamahiriya">Libyan Arab Jamahiriya
<option value="Liechtenstein">Liechtenstein
<option value="Lithuania">Lithuania
<option value="Luxembourg">Luxembourg
<option value="Macau">Macau
<option value="Macedonia">Macedonia
<option value="Madagascar">Madagascar
<option value="Malawi">Malawi
<option value="Malaysia">Malaysia
<option value="Maldives">Maldives
<option value="Mali">Mali
<option value="Malta">Malta
<option value="Marshall_Islands">Marshall Islands
<option value="Martinique">Martinique
<option value="Mauritania">Mauritania
<option value="Mauritius">Mauritius
<option value="Mayotte">Mayotte
<option value="Mexico">Mexico
<option value="Micronesia">Micronesia
<option value="Moldova">Moldova
<option value="Monaco">Monaco
<option value="Mongolia">Mongolia
<option value="Montserrat">Montserrat
<option value="Morocco">Morocco
<option value="Mozambique">Mozambique
<option value="Myanmar">Myanmar
<option value="Namibia">Namibia
<option value="Nauru">Nauru
<option value="Nepal">Nepal
<option value="Netherlands">Netherlands
<option value="Netherlands_Antilles">Netherlands Antilles
<option value="New_Caledonia">New Caledonia
<option value="New_Zealand">New Zealand
<option value="Nicaragua">Nicaragua
<option value="Niger">Niger
<option value="Nigeria">Nigeria
<option value="Niue">Niue
<option value="Norfolk_Island">Norfolk Island
<option value="Northern_Mariana_Islands">Northern Mariana Islands
<option value="Norway">Norway
<option value="Oman">Oman
<option value="Pakistan">Pakistan
<option value="Palau">Palau
<option value="Palestinian_Territory">Palestinian Territory, Occupied
<option value="Panama">Panama
<option value="Papua_New_Guinea">Papua New Guinea
<option value="Paraguay">Paraguay
<option value="Peru">Peru
<option value="Philippines">Philippines
<option value="Pitcairn">Pitcairn
<option value="Poland">Poland
<option value="Portugal">Portugal
<option value="Puerto_Rico">Puerto Rico
<option value="Qatar">Qatar
<option value="Reunion">Reunion
<option value="Romania">Romania
<option value="Russian_Federation">Russian Federation
<option value="Rwanda">Rwanda
<option value="Saint_Helena">Saint Helena
<option value="Saint_Kitts_Nevis">Saint Kitts and Nevis
<option value="Saint_Lucia">Saint Lucia
<option value="Saint_Pierre_Miquelon">Saint Pierre and Miquelon
<option value="Saint_Vincent_Grenadines">Saint Vincent and The Grenadines
<option value="Samoa">Samoa
<option value="San_Marino">San Marino
<option value="Sao_Tome_Principe">Sao Tome and Principe
<option value="Saudi_Arabia">Saudi Arabia
<option value="Senegal">Senegal
<option value="Seychelles">Seychelles
<option value="Sierra_Leone">Sierra Leone
<option value="Singapore">Singapore
<option value="Slovakia">Slovakia
<option value="Slovenia">Slovenia
<option value="Solomon_Islands">Solomon Islands
<option value="Somalia">Somalia
<option value="South_Africa">South Africa
<option value="South_Georgia">South Georgia And The South Sandwich Islands
<option value="Spain">Spain
<option value="Sri Lanka">Sri Lanka
<option value="Sudan">Sudan
<option value="Suriname">Suriname
<option value="Svalbard">Svalbard and Jan Mayen Islands
<option value="Swaziland">Swaziland
<option value="Sweden">Sweden
<option value="Switzerland">Switzerland
<option value="Syrian_Arab_Rep">Syrian Arab Rep.
<option value="Taiwan">Taiwan
<option value="Tajikistan">Tajikistan
<option value="Tanzania">Tanzania
<option value="Thailand">Thailand
<option value="Togo">Togo
<option value="Tokelau">Tokelau
<option value="Tonga">Tonga
<option value="Trinidad_Tobago">Trinidad and Tobago
<option value="Tunisia">Tunisia
<option value="Turkey">Turkey
<option value="Turkmenistan">Turkmenistan
<option value="Turks_Caicos_Islands">Turks and Caicos Islands
<option value="Tuvalu">Tuvalu
<option value="Uganda">Uganda
<option value="Ukraine">Ukraine
<option value="United_Arab_Emirates">United Arab Emirates
<option value="UK">United Kingdom
<option value="US">United States
<option value="US_Minor_Outlying_Islands">United States Minor Outlying
Islands
<option value="Uruguay">Uruguay
<option value="Uzbekistan">Uzbekistan
<option value="Vanuatu">Vanuatu
<option value="Vatican_City_State">Vatican City State (Holy See)
<option value="Venezuela">Venezuela
<option value="Vietnam">Viet Nam
<option value="Virgin_Islands_Brit">Virgin Islands (British)
<option value="Virgin_Islands_US">Virgin Islands (US)
<option value="Wallis_Futuna_Islands">Wallis and Futuna Islands
<option value="Western_Sahara">Western Sahara
<option value="Yemen">Yemen
<option value="Yugoslavia">Yugoslavia
<option value="Zambia">Zambia
<option value="Zimbabwe">Zimbabwe
</select></td>
</tr>
<tr>
<td>&nbsp;</td>
<td>&nbsp;</td>
</tr>
<tr>
<td>Telephone*</td>
<td><font face="Arial" size="2">
<input type="text" name="Telephone" size="15" maxlength="20">
</font></td>
</tr>
<tr>
<td>Fax</td>
<td><font face="Arial" size="2">
<input type="text" name="Fax" size="15" maxlength="20">
</font></td>
</tr>
<tr>
<td>&nbsp;</td>
<td>&nbsp;</td>
</tr>
<tr>
<td>Email<font color="#FF0000">*</font></td>
<td><font face="Arial" size="2">
<input name="email" type="text" id="email" size="30" maxlength="100">
</font></td>
</tr>
<tr>
<td>Message</td>
<td><textarea name="Message" cols="25" rows="4" id="Message"></textarea></td>
</tr>
<tr>
<td colspan="2"><font face="Arial" size="2">
<input type="checkbox" name="addrecords" value="YES" id="fp1">
<label for="fp1">Please add my email address to your records.</label>
</font> <font face="Arial" size="2">&nbsp; </font></td>
</tr>
<tr>
<td colspan="2"><font face="Arial" size="2">
<input type="checkbox" name="promo" value="YES" id="fp2">
Send me promotionals items. </font></td>
</tr>
</table>
<p align="center" class="button">&nbsp;&nbsp;&nbsp;&nbsp;
<input name="Submit" type="submit" class="button1" id="Submit" value="Submit">
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
<input name="Reset" type="reset" class="button1" id="Reset" value="Reset">
< /p>
<p align="center" class="button">&nbsp; </p></td>
</tr>
<tr>
<td bgcolor="#dddddd"><div align="center"><a href="http://www.uniweb.be">UniMailer V1.2</a></div></td>
</tr>
< /table>
< /form>
< /body>
< /html>