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<form action=”http://kekulicafe.createsend.com/t/t/s/nldft/” method=”post” id=”subForm”>
<p>
<label for=”fieldName”>Name</label><br />
<input id=”fieldName” name=”cm-name” type=”text” />
</p>
<p>
<label for=”fieldEmail”>Email</label><br />
<input id=”fieldEmail” name=”cm-nldft-nldft” type=”email” required />
</p>
<p>
<label for=”fieldbjyurh”>City</label><br />
<input id=”fieldbjyurh” name=”cm-f-bjyurh” type=”text” />
</p>
<p>
<label for=”fieldbjyurk”>Province</label><br />
<input id=”fieldbjyurk” name=”cm-f-bjyurk” type=”text” />
</p>
<p>
<label for=”fieldbjyuru”>Date of Birth</label><br />
<select id=”fieldbjyuru” name=”cm-fd-bjyuru-mn”><option value=””></option><option value=”1″>Jan</option><option value=”2″>Feb</option><option value=”3″>Mar</option><option value=”4″>Apr</option><option value=”5″>May</option><option value=”6″>Jun</option><option value=”7″>Jul</option><option value=”8″>Aug</option><option value=”9″>Sep</option><option value=”10″>Oct</option><option value=”11″>Nov</option><option value=”12″>Dec</option></select>
<select id=”fieldbjyurudy” name=”cm-fd-bjyuru-dy”><option value=””></option><option value=”1″>1</option><option value=”2″>2</option><option value=”3″>3</option><option value=”4″>4</option><option value=”5″>5</option><option value=”6″>6</option><option value=”7″>7</option><option value=”8″>8</option><option value=”9″>9</option><option value=”10″>10</option><option value=”11″>11</option><option value=”12″>12</option><option value=”13″>13</option><option value=”14″>14</option><option value=”15″>15</option><option value=”16″>16</option><option value=”17″>17</option><option value=”18″>18</option><option value=”19″>19</option><option value=”20″>20</option><option value=”21″>21</option><option value=”22″>22</option><option value=”23″>23</option><option value=”24″>24</option><option value=”25″>25</option><option value=”26″>26</option><option value=”27″>27</option><option value=”28″>28</option><option value=”29″>29</option><option value=”30″>30</option><option value=”31″>31</option></select>
<select id=”fieldbjyuruyr” name=”cm-fd-bjyuru-yr”><option value=””></option><option value=”1901″>1901</option><option value=”1902″>1902</option><option value=”1903″>1903</option><option value=”1904″>1904</option><option value=”1905″>1905</option><option value=”1906″>1906</option><option value=”1907″>1907</option><option value=”1908″>1908</option><option value=”1909″>1909</option><option value=”1910″>1910</option><option value=”1911″>1911</option><option value=”1912″>1912</option><option value=”1913″>1913</option><option value=”1914″>1914</option><option value=”1915″>1915</option><option value=”1916″>1916</option><option value=”1917″>1917</option><option value=”1918″>1918</option><option value=”1919″>1919</option><option value=”1920″>1920</option><option value=”1921″>1921</option><option value=”1922″>1922</option><option value=”1923″>1923</option><option value=”1924″>1924</option><option value=”1925″>1925</option><option value=”1926″>1926</option><option value=”1927″>1927</option><option value=”1928″>1928</option><option value=”1929″>1929</option><option value=”1930″>1930</option><option value=”1931″>1931</option><option value=”1932″>1932</option><option value=”1933″>1933</option><option value=”1934″>1934</option><option value=”1935″>1935</option><option value=”1936″>1936</option><option value=”1937″>1937</option><option value=”1938″>1938</option><option value=”1939″>1939</option><option value=”1940″>1940</option><option value=”1941″>1941</option><option value=”1942″>1942</option><option value=”1943″>1943</option><option value=”1944″>1944</option><option value=”1945″>1945</option><option value=”1946″>1946</option><option value=”1947″>1947</option><option value=”1948″>1948</option><option value=”1949″>1949</option><option value=”1950″>1950</option><option value=”1951″>1951</option><option value=”1952″>1952</option><option value=”1953″>1953</option><option value=”1954″>1954</option><option value=”1955″>1955</option><option value=”1956″>1956</option><option value=”1957″>1957</option><option value=”1958″>1958</option><option value=”1959″>1959</option><option value=”1960″>1960</option><option value=”1961″>1961</option><option value=”1962″>1962</option><option value=”1963″>1963</option><option value=”1964″>1964</option><option value=”1965″>1965</option><option value=”1966″>1966</option><option value=”1967″>1967</option><option value=”1968″>1968</option><option value=”1969″>1969</option><option value=”1970″>1970</option><option value=”1971″>1971</option><option value=”1972″>1972</option><option value=”1973″>1973</option><option value=”1974″>1974</option><option value=”1975″>1975</option><option value=”1976″>1976</option><option value=”1977″>1977</option><option value=”1978″>1978</option><option value=”1979″>1979</option><option value=”1980″>1980</option><option value=”1981″>1981</option><option value=”1982″>1982</option><option value=”1983″>1983</option><option value=”1984″>1984</option><option value=”1985″>1985</option><option value=”1986″>1986</option><option value=”1987″>1987</option><option value=”1988″>1988</option><option value=”1989″>1989</option><option value=”1990″>1990</option><option value=”1991″>1991</option><option value=”1992″>1992</option><option value=”1993″>1993</option><option value=”1994″>1994</option><option value=”1995″>1995</option><option value=”1996″>1996</option><option value=”1997″>1997</option><option value=”1998″>1998</option><option value=”1999″>1999</option><option value=”2000″>2000</option><option value=”2001″>2001</option><option value=”2002″>2002</option><option value=”2003″>2003</option><option value=”2004″>2004</option><option value=”2005″>2005</option><option value=”2006″>2006</option><option value=”2007″>2007</option><option value=”2008″>2008</option><option value=”2009″>2009</option><option value=”2010″>2010</option><option value=”2011″>2011</option><option value=”2012″>2012</option><option value=”2013″>2013</option><option value=”2014″>2014</option><option value=”2015″>2015</option><option value=”2016″>2016</option><option value=”2017″>2017</option><option value=”2018″>2018</option><option value=”2019″>2019</option><option value=”2020″>2020</option><option value=”2021″>2021</option><option value=”2022″>2022</option><option value=”2023″>2023</option><option value=”2024″>2024</option><option value=”2025″>2025</option><option value=”2026″>2026</option><option value=”2027″>2027</option><option value=”2028″>2028</option><option value=”2029″>2029</option><option value=”2030″>2030</option><option value=”2031″>2031</option><option value=”2032″>2032</option><option value=”2033″>2033</option><option value=”2034″>2034</option><option value=”2035″>2035</option><option value=”2036″>2036</option><option value=”2037″>2037</option><option value=”2038″>2038</option><option value=”2039″>2039</option><option value=”2040″>2040</option><option value=”2041″>2041</option><option value=”2042″>2042</option><option value=”2043″>2043</option><option value=”2044″>2044</option><option value=”2045″>2045</option><option value=”2046″>2046</option><option value=”2047″>2047</option><option value=”2048″>2048</option><option value=”2049″>2049</option><option value=”2050″>2050</option><option value=”2051″>2051</option><option value=”2052″>2052</option><option value=”2053″>2053</option><option value=”2054″>2054</option><option value=”2055″>2055</option><option value=”2056″>2056</option><option value=”2057″>2057</option><option value=”2058″>2058</option><option value=”2059″>2059</option><option value=”2060″>2060</option><option value=”2061″>2061</option><option value=”2062″>2062</option><option value=”2063″>2063</option><option value=”2064″>2064</option><option value=”2065″>2065</option><option value=”2066″>2066</option><option value=”2067″>2067</option><option value=”2068″>2068</option><option value=”2069″>2069</option><option value=”2070″>2070</option><option value=”2071″>2071</option><option value=”2072″>2072</option><option value=”2073″>2073</option><option value=”2074″>2074</option><option value=”2075″>2075</option><option value=”2076″>2076</option><option value=”2077″>2077</option><option value=”2078″>2078</option></select>
</p>
<p>
<button type=”submit”>Subscribe</button>
</p>
</form>

 

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