Here is the form's code:
<img style="float:right" width="365px" alt="Image Goes Here" src="images/tip_signup.jpg" />
<table
style="width: 565px; height: 314px; text-align: left; margin-left: auto; margin-right: auto;"
border="0" cellpadding="2" cellspacing="2">
<tbody>
<tr>
<td style="vertical-align: top;" colspan="2"
rowspan="1">
<!-- enter message here -->
<b>I would like to receive your monthly e-mail tips offering proven effective ways to enhance my agency’s foster parent recruiting efforts. I understand these are free and there is no obligation whatsoever.<br><br>
Here is my information.</b>
<!-- end message here -->
</td>
</tr>
<tr>
<td align="undefined" valign="undefined">Name</td>
<td align="undefined" valign="undefined"><input
size="40" maxlength="40" name="Name"></td>
</tr>
<tr>
<td align="undefined" valign="undefined">Title</td>
<td align="undefined" valign="undefined"><input
maxlength="25" size="25" name="Title"></td>
</tr>
<tr>
<td align="undefined" valign="undefined">Agency</td>
<td align="undefined" valign="undefined"><input
size="20" name="Agency"></td>
</tr>
<tr>
<td align="undefined" valign="undefined">E-Mail</td>
<td align="undefined" valign="undefined"><input
maxlength="40" size="40" name="Email"></td>
</tr>
<tr>
<td colspan="2" rowspan="1"
align="undefined" valign="undefined"><input type="submit"
style="height: 50px; width: 100px; color:black" value="Submit"
name="Submit"/></td>
</tr>
</tbody>
</table>
<input readonly size="300" name="referer" type="hidden" value='
<?php
echo $_SERVER['HTTP_REFERER'];
?>
'></input>
Here is the "on Submit Code":
<img style="float:right" width="365px" alt="Image Goes Here" src="images/tip_signup.jpg" />
<div style="text-align: center; font-weight: bold;">Thank you for entering your information.<br>You will be signed up to receive E-mail tips.
<br>