[:en]<form action="https://webto.salesforce.com/servlet/servlet.WebToLead?encoding=UTF-8&orgId=00DHp000003Tpx3" method="POST">
    <input type=hidden name="oid" value="00DHp000003Tpx3">
    <input type=hidden name="retURL" value="https://chocolatecordillera.com/thank-you">
    <div class="row align-items-center">
        <div class="col-12 col-md-6">
            <input  id="first_name" maxlength="40" name="first_name" size="20" type="text" placeholder="First Name" class="the-input" />
        </div>
        <div class="col-12 col-md-6">
            <input  id="last_name" maxlength="80" name="last_name" size="20" type="text" placeholder="Last Name" class="the-input" />
        </div>
        <div class="col-12 col-md-6">
            <input  id="email" maxlength="80" name="email" size="20" type="text" placeholder="Email" class="the-input" />
        </div>
        <div class="col-12 col-md-6">
            <input  id="phone" maxlength="40" name="phone" size="20" type="text" placeholder="Phone" class="the-input" />
        </div>
        <div class="col-12 col-md-6">
            <input  id="company" maxlength="40" name="company" size="20" type="text" placeholder="Company" class="the-input" />
        </div>
        <div class="col-12 col-md-6">
            <input  id="url" maxlength="80" name="url" size="20" type="text" placeholder="Website" class="the-input" />
        </div>
        <div class="col-12 col-md-4">
            <input  id="country" maxlength="40" name="country" size="20" type="text" placeholder="Country" class="the-input" />
        </div>
        <div class="col-12 col-md-4">
            <select  id="00NHp000012MS4r" name="00NHp000012MS4r" class="the-select" title="Role">
                <option value="">Select role</option>
                <option value="Manager">Manager</option>
                <option value="Chef - Pastry Baker">Chef - Pastry Baker</option>
                <option value="R&DDirector">R&DDirector</option>
                <option value="Procurement">Procurement</option>
                <option value="Other">Other</option>
            </select>
        </div>
        <div class="col-12 col-md-4">
            <select  id="lead_source" name="lead_source" class="the-select">
                <option value="">How did you discover Cordillera</option>
                <option value="Search (Google, Yahoo, etc)">Search (Google, Yahoo, etc)</option>
                <option value="Recommended by friend or colleague">Recommended by friend or colleague</option>
                <option value="Social media">Social media</option>
                <option value="Blog or publication">Blog or publication</option>
                <option value="Other">Other</option>
                <option value="Online Search">Online Search</option>
                <option value="Word-of-Mouth">Word-of-Mouth</option>
                <option value="Trade Show">Trade Show</option>
                <option value="Printed Media">Printed Media</option>
            </select>
        </div>
        <div class="col-12">
            <select  id="00NHp000012MS4o" name="00NHp000012MS4o" class="the-select" title="Industry segment">
                <option value="">Industry segment</option>
                <option value="Multicategory">Multicategory</option>
                <option value="Bakery">Bakery</option>
                <option value="Confectionary">Confectionary</option>
                <option value="Beverage">Beverage</option>
                <option value="Snacks (Bars)">Snacks (Bars)</option>
                <option value="Distributor">Distributor</option>
                <option value="Snacks">Snacks</option>
            </select>
        </div>
        <div class="col-12">
            <textarea name="description" placeholder="Description"></textarea>
        </div>
        <div class="col-12 col-md-9">
            <label class="police">
                <input  id="00NHp000012MS4p" name="00NHp000012MS4p" type="checkbox" value="1" />
                <span class="check"></span>
                <span class="text">I agree to the terms and conditions</span>
            </label>
        </div>
        <div class="col-12 col-md-3">
            <input type="submit" name="submit" value="Send">
            <input type=hidden name="recordType" id="recordType" value="012Hp000001nRV8">
        </div>
    </div>
</form>[:]