<form action="https://cl.exct.net/subscribe.aspx" class="generic_form" id="subscribeForm" method="post" name="subscribeForm"><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input name="thx" type="hidden" value="Link to your success or thank you page here"/><!-- [et_pb_line_break_holder] --><input name="err" type="hidden" value="Link to your error page here"/><!-- [et_pb_line_break_holder] --><input name="usub" type="hidden" value="Link to your thanks you have unsubscribed page here"/><!-- [et_pb_line_break_holder] --><input name="MID" type="hidden" value="YOUR MID # GOES HERE"/><!-- [et_pb_line_break_holder] --><input id="subkey" name="ETSubscriberKey" type="hidden" value=""/><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><fieldset><!-- [et_pb_line_break_holder] --><legend>Subscribe</legend> <!-- [et_pb_line_break_holder] --><p><label for="first">First Name</label><br/><!-- [et_pb_line_break_holder] --><input id="first" name="First Name" size="25" type="text"/></p><!-- [et_pb_line_break_holder] --><p><label for="last">Last Name</label><br/><!-- [et_pb_line_break_holder] --><input id="last" name="Last Name" size="25" type="text"/></p><!-- [et_pb_line_break_holder] --><p><label for="email">* E-mail Address</label><br/><!-- [et_pb_line_break_holder] --><input id="email" name="Email Address" size="25" type="text"/></p><!-- [et_pb_line_break_holder] --><fieldset><!-- [et_pb_line_break_holder] --><p>Please subscribe me to:</p><!-- [et_pb_line_break_holder] --><p><input checked="checked" id="slid_10" name="lid" type="checkbox" value="LIST ID# GOES HERE"/><!-- [et_pb_line_break_holder] --><label for="slid_10"> NAME OF LIST</label><br/><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --></fieldset><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><fieldset><!-- [et_pb_line_break_holder] --><p><input id="plain" name="Email Type" type="radio" value="TEXT"/><!-- [et_pb_line_break_holder] --><label for="plain"> Plain-text</label><br/><!-- [et_pb_line_break_holder] --><input checked="checked" id="html" name="Email Type" type="radio" value="HTML"/><!-- [et_pb_line_break_holder] --><label for="html"> HTML</label></p><!-- [et_pb_line_break_holder] --><p><input checked="checked" id="sub" name="SubAction" type="radio" value="sub_add_update"/><!-- [et_pb_line_break_holder] --><label for="sub"> Subscribe</label><br/><!-- [et_pb_line_break_holder] --><input id="unsub" name="SubAction" type="radio" value="unsub"/><!-- [et_pb_line_break_holder] --><label for="unsub"> Unsubscribe</label></p><!-- [et_pb_line_break_holder] --></fieldset><!-- [et_pb_line_break_holder] --><input id="form-submit-subscribe" name="submit" type="submit" value="Submit"/><!-- [et_pb_line_break_holder] --></fieldset><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --></form>

<script> <!-- [et_pb_line_break_holder] --> $("#email").focusout( function(){<!-- [et_pb_line_break_holder] --> $("#subkey").val( $("#email").val() + "." + $("input[name='MID']").val() );<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --></script>