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jbro-io/bluume web-to-lead

Last active August 29, 2015 14:08
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bluume web-to-lead
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: Please add the following <META> element to your page <HEAD>. -->
<!-- If necessary, please modify the charset parameter to specify the -->
<!-- character set of your HTML page. -->
<!-- ---------------------------------------------------------------------- -->
<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: Please add the following <FORM> element to your page. -->
<!-- ---------------------------------------------------------------------- -->
<form action="https://www.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8" method="POST">
<input type=hidden name="oid" value="00Do0000000L2cM">
<input type=hidden name="retURL" value="http://YOUR_RETURN_URL_HERE">
<input type=hidden name="lead_source" value="Web">
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: These fields are optional debugging elements. Please uncomment -->
<!-- these lines if you wish to test in debug mode. -->
<!-- <input type="hidden" name="debug" value=1> -->
<!-- <input type="hidden" name="debugEmail" value="jon@bluume.com"> -->
<!-- ---------------------------------------------------------------------- -->
<label for="first_name">First Name</label><input id="first_name" maxlength="40" name="first_name" size="20" type="text" /><br>
<label for="last_name">Last Name</label><input id="last_name" maxlength="80" name="last_name" size="20" type="text" /><br>
<label for="company">Company</label><input id="company" maxlength="40" name="company" size="20" type="text" /><br>
<label for="email">Email</label><input id="email" maxlength="80" name="email" size="20" type="text" /><br>
<label for="phone">Phone</label><input id="phone" maxlength="40" name="phone" size="20" type="text" /><br>
<label for="title">Title</label><input id="title" maxlength="40" name="title" size="20" type="text" /><br>
<label for="street">Address</label><textarea name="street"></textarea><br>
<label for="city">City</label><input id="city" maxlength="40" name="city" size="20" type="text" /><br>
<label for="country_code">Country</label><select id="country_code" name="country_code"><option value="">--None--</option><option value="AF">Afghanistan</option>
<option value="AX">Aland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia, Plurinational State of</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="TW">Chinese Taipei</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, the Democratic Republic of the</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Cote d&#39;Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran, Islamic Republic of</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea, Democratic People&#39;s Republic of</option>
<option value="KR">Korea, Republic of</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People&#39;s Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MK">Macedonia, the former Yugoslav Republic of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="MD">Moldova, Republic of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PS">Palestinian Territory, Occupied</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic of</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela, Bolivarian Republic of</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands, British</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select><br>
<label for="state_code">State/Province</label><select id="state_code" name="state_code"><option value="">--None--</option><option value="AC">Acre</option>
<option value="AG">Agrigento</option>
<option value="AG">Aguascalientes</option>
<option value="AL">Alabama</option>
<option value="AL">Alagoas</option>
<option value="AK">Alaska</option>
<option value="AB">Alberta</option>
<option value="AL">Alessandria</option>
<option value="AP">Amapá</option>
<option value="AM">Amazonas</option>
<option value="AN">Ancona</option>
<option value="AN">Andaman and Nicobar Islands</option>
<option value="AP">Andhra Pradesh</option>
<option value="34">Anhui</option>
<option value="AO">Aosta</option>
<option value="AR">Arezzo</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="AR">Arunachal Pradesh</option>
<option value="AP">Ascoli Piceno</option>
<option value="AS">Assam</option>
<option value="AT">Asti</option>
<option value="ACT">Australian Capital Territory</option>
<option value="AV">Avellino</option>
<option value="BA">Bahia</option>
<option value="BC">Baja California</option>
<option value="BS">Baja California Sur</option>
<option value="BA">Bari</option>
<option value="BT">Barletta-Andria-Trani</option>
<option value="11">Beijing</option>
<option value="BL">Belluno</option>
<option value="BN">Benevento</option>
<option value="BG">Bergamo</option>
<option value="BI">Biella</option>
<option value="BR">Bihar</option>
<option value="BO">Bologna</option>
<option value="BZ">Bolzano</option>
<option value="BS">Brescia</option>
<option value="BR">Brindisi</option>
<option value="BC">British Columbia</option>
<option value="CA">Cagliari</option>
<option value="CA">California</option>
<option value="CL">Caltanissetta</option>
<option value="CM">Campeche</option>
<option value="CB">Campobasso</option>
<option value="CI">Carbonia-Iglesias</option>
<option value="CW">Carlow</option>
<option value="CE">Caserta</option>
<option value="CT">Catania</option>
<option value="CZ">Catanzaro</option>
<option value="CN">Cavan</option>
<option value="CE">Ceará</option>
<option value="CH">Chandigarh</option>
<option value="CT">Chhattisgarh</option>
<option value="CS">Chiapas</option>
<option value="CH">Chieti</option>
<option value="CH">Chihuahua</option>
<option value="71">Chinese Taipei</option>
<option value="50">Chongqing</option>
<option value="CE">Clare</option>
<option value="CO">Coahuila</option>
<option value="CL">Colima</option>
<option value="CO">Colorado</option>
<option value="CO">Como</option>
<option value="CT">Connecticut</option>
<option value="CO">Cork</option>
<option value="CS">Cosenza</option>
<option value="CR">Cremona</option>
<option value="KR">Crotone</option>
<option value="CN">Cuneo</option>
<option value="DN">Dadra and Nagar Haveli</option>
<option value="DD">Daman and Diu</option>
<option value="DE">Delaware</option>
<option value="DL">Delhi</option>
<option value="DC">District of Columbia</option>
<option value="DF">Distrito Federal</option>
<option value="DL">Donegal</option>
<option value="D">Dublin</option>
<option value="DG">Durango</option>
<option value="EN">Enna</option>
<option value="ES">Espírito Santo</option>
<option value="DF">Federal District</option>
<option value="FM">Fermo</option>
<option value="FE">Ferrara</option>
<option value="FI">Florence</option>
<option value="FL">Florida</option>
<option value="FG">Foggia</option>
<option value="FC">Forlì-Cesena</option>
<option value="FR">Frosinone</option>
<option value="35">Fujian</option>
<option value="G">Galway</option>
<option value="62">Gansu</option>
<option value="GE">Genoa</option>
<option value="GA">Georgia</option>
<option value="GA">Goa</option>
<option value="GO">Goiás</option>
<option value="GO">Gorizia</option>
<option value="GR">Grosseto</option>
<option value="GT">Guanajuato</option>
<option value="44">Guangdong</option>
<option value="45">Guangxi</option>
<option value="GR">Guerrero</option>
<option value="52">Guizhou</option>
<option value="GJ">Gujarat</option>
<option value="46">Hainan</option>
<option value="HR">Haryana</option>
<option value="HI">Hawaii</option>
<option value="13">Hebei</option>
<option value="23">Heilongjiang</option>
<option value="41">Henan</option>
<option value="HG">Hidalgo</option>
<option value="HP">Himachal Pradesh</option>
<option value="91">Hong Kong</option>
<option value="42">Hubei</option>
<option value="43">Hunan</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IM">Imperia</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="IS">Isernia</option>
<option value="JA">Jalisco</option>
<option value="JK">Jammu and Kashmir</option>
<option value="JH">Jharkhand</option>
<option value="32">Jiangsu</option>
<option value="36">Jiangxi</option>
<option value="22">Jilin</option>
<option value="KS">Kansas</option>
<option value="KA">Karnataka</option>
<option value="KY">Kentucky</option>
<option value="KL">Kerala</option>
<option value="KY">Kerry</option>
<option value="KE">Kildare</option>
<option value="KK">Kilkenny</option>
<option value="AQ">L&#39;Aquila</option>
<option value="LD">Lakshadweep</option>
<option value="LS">Laois</option>
<option value="SP">La Spezia</option>
<option value="LT">Latina</option>
<option value="LE">Lecce</option>
<option value="LC">Lecco</option>
<option value="LM">Leitrim</option>
<option value="21">Liaoning</option>
<option value="LK">Limerick</option>
<option value="LI">Livorno</option>
<option value="LO">Lodi</option>
<option value="LD">Longford</option>
<option value="LA">Louisiana</option>
<option value="LH">Louth</option>
<option value="LU">Lucca</option>
<option value="92">Macao</option>
<option value="MC">Macerata</option>
<option value="MP">Madhya Pradesh</option>
<option value="MH">Maharashtra</option>
<option value="ME">Maine</option>
<option value="MN">Manipur</option>
<option value="MB">Manitoba</option>
<option value="MN">Mantua</option>
<option value="MA">Maranhão</option>
<option value="MD">Maryland</option>
<option value="MS">Massa and Carrara</option>
<option value="MA">Massachusetts</option>
<option value="MT">Matera</option>
<option value="MT">Mato Grosso</option>
<option value="MS">Mato Grosso do Sul</option>
<option value="MO">Mayo</option>
<option value="MH">Meath</option>
<option value="VS">Medio Campidano</option>
<option value="ML">Meghalaya</option>
<option value="ME">Messina</option>
<option value="ME">Mexico State</option>
<option value="MI">Michigan</option>
<option value="MI">Michoacán</option>
<option value="MI">Milan</option>
<option value="MG">Minas Gerais</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MZ">Mizoram</option>
<option value="MO">Modena</option>
<option value="MN">Monaghan</option>
<option value="MT">Montana</option>
<option value="MB">Monza and Brianza</option>
<option value="MO">Morelos</option>
<option value="NL">Nagaland</option>
<option value="NA">Naples</option>
<option value="NA">Nayarit</option>
<option value="NE">Nebraska</option>
<option value="15">Nei Mongol</option>
<option value="NV">Nevada</option>
<option value="NB">New Brunswick</option>
<option value="NL">Newfoundland and Labrador</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NSW">New South Wales</option>
<option value="NY">New York</option>
<option value="64">Ningxia</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="NT">Northern Territory</option>
<option value="NT">Northwest Territories</option>
<option value="NO">Novara</option>
<option value="NS">Nova Scotia</option>
<option value="NL">Nuevo León</option>
<option value="NU">Nunavut</option>
<option value="NU">Nuoro</option>
<option value="OA">Oaxaca</option>
<option value="OR">Odisha</option>
<option value="OY">Offaly</option>
<option value="OG">Ogliastra</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OT">Olbia-Tempio</option>
<option value="ON">Ontario</option>
<option value="OR">Oregon</option>
<option value="OR">Oristano</option>
<option value="PD">Padua</option>
<option value="PA">Palermo</option>
<option value="PA">Pará</option>
<option value="PB">Paraíba</option>
<option value="PR">Paraná</option>
<option value="PR">Parma</option>
<option value="PV">Pavia</option>
<option value="PA">Pennsylvania</option>
<option value="PE">Pernambuco</option>
<option value="PG">Perugia</option>
<option value="PU">Pesaro and Urbino</option>
<option value="PE">Pescara</option>
<option value="PC">Piacenza</option>
<option value="PI">Piauí</option>
<option value="PI">Pisa</option>
<option value="PT">Pistoia</option>
<option value="PN">Pordenone</option>
<option value="PZ">Potenza</option>
<option value="PO">Prato</option>
<option value="PE">Prince Edward Island</option>
<option value="PY">Puducherry</option>
<option value="PB">Puebla</option>
<option value="PB">Punjab</option>
<option value="63">Qinghai</option>
<option value="QC">Quebec</option>
<option value="QLD">Queensland</option>
<option value="QE">Querétaro</option>
<option value="QR">Quintana Roo</option>
<option value="RG">Ragusa</option>
<option value="RJ">Rajasthan</option>
<option value="RA">Ravenna</option>
<option value="RC">Reggio Calabria</option>
<option value="RE">Reggio Emilia</option>
<option value="RI">Rhode Island</option>
<option value="RI">Rieti</option>
<option value="RN">Rimini</option>
<option value="RJ">Rio de Janeiro</option>
<option value="RN">Rio Grande do Norte</option>
<option value="RS">Rio Grande do Sul</option>
<option value="RM">Rome</option>
<option value="RO">Rondônia</option>
<option value="RR">Roraima</option>
<option value="RN">Roscommon</option>
<option value="RO">Rovigo</option>
<option value="SA">Salerno</option>
<option value="SL">San Luis Potosí</option>
<option value="SC">Santa Catarina</option>
<option value="SP">São Paulo</option>
<option value="SK">Saskatchewan</option>
<option value="SS">Sassari</option>
<option value="SV">Savona</option>
<option value="SE">Sergipe</option>
<option value="61">Shaanxi</option>
<option value="37">Shandong</option>
<option value="31">Shanghai</option>
<option value="14">Shanxi</option>
<option value="51">Sichuan</option>
<option value="SI">Siena</option>
<option value="SK">Sikkim</option>
<option value="SI">Sinaloa</option>
<option value="SO">Sligo</option>
<option value="SO">Sondrio</option>
<option value="SO">Sonora</option>
<option value="SA">South Australia</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="SR">Syracuse</option>
<option value="TB">Tabasco</option>
<option value="TM">Tamaulipas</option>
<option value="TN">Tamil Nadu</option>
<option value="TA">Taranto</option>
<option value="TAS">Tasmania</option>
<option value="TN">Tennessee</option>
<option value="TE">Teramo</option>
<option value="TR">Terni</option>
<option value="TX">Texas</option>
<option value="12">Tianjin</option>
<option value="TA">Tipperary</option>
<option value="TL">Tlaxcala</option>
<option value="TO">Tocantins</option>
<option value="TP">Trapani</option>
<option value="TN">Trento</option>
<option value="TV">Treviso</option>
<option value="TS">Trieste</option>
<option value="TR">Tripura</option>
<option value="TO">Turin</option>
<option value="UD">Udine</option>
<option value="UT">Utah</option>
<option value="UT">Uttarakhand</option>
<option value="UP">Uttar Pradesh</option>
<option value="VA">Varese</option>
<option value="VE">Venice</option>
<option value="VE">Veracruz</option>
<option value="VB">Verbano-Cusio-Ossola</option>
<option value="VC">Vercelli</option>
<option value="VT">Vermont</option>
<option value="VR">Verona</option>
<option value="VV">Vibo Valentia</option>
<option value="VI">Vicenza</option>
<option value="VIC">Victoria</option>
<option value="VA">Virginia</option>
<option value="VT">Viterbo</option>
<option value="WA">Washington</option>
<option value="WD">Waterford</option>
<option value="WB">West Bengal</option>
<option value="WA">Western Australia</option>
<option value="WH">Westmeath</option>
<option value="WV">West Virginia</option>
<option value="WX">Wexford</option>
<option value="WW">Wicklow</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="65">Xinjiang</option>
<option value="54">Xizang</option>
<option value="YU">Yucatán</option>
<option value="YT">Yukon Territories</option>
<option value="53">Yunnan</option>
<option value="ZA">Zacatecas</option>
<option value="33">Zhejiang</option>
</select><br>
<label for="zip">Zip</label><input id="zip" maxlength="20" name="zip" size="20" type="text" /><br>
<label for="description">Description</label><textarea name="description"></textarea><br>
<input type="submit" name="submit">
</form>
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