<div class="item ">
[text txtname class:membership placeholder "Name"]
</div>
<div class="item ">
[text txtcompanyname class:membership placeholder "Company/Institution name"]
</div>
<div class="item ">
[email* txtemail class:membership placeholder "Email ID"]
</div>
<div class="item ">
[text txtmobile class:membership placeholder "Mobile"]
</div>
<div class="item ">
[select country "Select Country" "India" "Afghanistan" "Albania" "Algeria" "American Samoa" "Andorra" "Angola" "Anguilla" "Antarctica" "Antigua and Barbuda" "Argentina" "Armenia" "Aruba" "Australia" "Austria" "Azerbaijan" "Bahamas" "Bahrain" "Bangladesh" "Barbados" "Belarus" "Belgium" "Belize" "Benin" "Bermuda" "Bhutan" "Bolivia" "Bosnia and Herzegowina" "Botswana" "Bouvet Island" "Brazil" "British Indian Ocean Territory" "Brunei Darussalam" "Bulgaria" "Burkina Faso" "Burundi" "Cambodia" "Cameroon" "Canada" "Cape Verde" "Cayman Islands" "Central African Republic" "Chad" "Chile" "China" "Christmas Island" "Cocos (Keeling) Islands" "Colombia" "Comoros" "Congo" "Cook Islands" "Costa Rica" "Croatia (local name: Hrvatska)" "Cuba" "Cyprus" "Czech Republic" "Denmark" "Djibouti" "Dominica" "Dominican Republic" "East Timor" "Ecuador" "Egypt" "El Salvador" "Equatorial Guinea" "Eritrea" "Estonia" "Ethiopia" "Falkland Islands (Malvinas)" "Faroe Islands" "Fiji" "Finland" "France" "France Metropolitan" "French Guiana" "French Polynesia" "French Southern Territories" "Gabon" "Gambia" "Georgia" "Germany" "Ghana" "Gibraltar" "Greece" "Greenland" "Grenada" "Guadeloupe" "Guam" "Guatemala" "Guinea" "Guinea-Bissau" "Guyana" "Haiti" "Heard and Mc Donald Islands" "Honduras" "Hong Kong" "Hungary" "Iceland" "Indonesia" "Iran (Islamic Republic of Iraq" "Ireland" "Israel" "Italy" "Jamaica" "Japan" "Jordan" "Kazakhstan" "Kenya" "Kiribati" "Kuwait" "Kyrgyzstan" "Latvia" "Lebanon" "Lesotho" "Liberia" "Libyan Arab Jamahiriya" "Liechtenstein" "Lithuania" "Luxembourg" " Macao" "Macedonia" "Madagascar" "Malawi" " Malaysia" "Maldives" "Mali" "Malta" "Marshall Islands" "Martinique" "Mauritania" "Mauritius" "Mayotte" "Mexico" "Micronesia" "Moldova" "Monaco" "Mongolia" "Montserrat" "Morocco" "Mozambique" "Myanmar" "Namibia" "Nauru" "Nepal" "Netherlands" "Netherlands Antilles" "New Caledonia" "New Zealand" "Nicaragua" "Niger" "Nigeria" "Niue" "Norfolk Island" "North Korea" "Northern Mariana Islands" "Norway" "Oman" "Pakistan" "Palau" "Panama" "Papua New Guinea" "Paraguay" "Peru" "Philippines" "Pitcairn" "Poland" "Portugal" "Puerto Rico" "Qatar" "Reunion" "Romania" "Russian Federation" "Rwanda" "Saint Kitts and Nevis" "Saint Lucia" "Saint Vincent and the Grenadines" "Samoa" "San Marino" "Sao Tome and Principe" "Saudi Arabia" "Senegal" "Seychelles" "Sierra Leone" "Singapore" "Slovakia (Slovak Republic)" "Slovenia" "Solomon Islands" "Somalia" "South Africa" "South Korea" "Spain" "Sri Lanka" "St. Helena" "St. Pierre and Miquelon" "Sudan" "Suriname" "Svalbard and Jan Mayen Islands" "Swaziland" "Sweden" "Switzerland" "Syrian Arab Republic" "Taiwan" "Tajikistan" "Tanzania" "Thailand" "Togo" "Tokelau" "Tonga" "Trinidad and Tobago" "Tunisia" "Turkey" "Turkmenistan" "Turks and Caicos Islands" "Tuvalu" "Uganda" "Ukraine" "United Arab Emirates" "United Kingdom" "United States" " United States Minor Outlying Islands" "Uruguay" "Uzbekistan" "Vanuatu" "Vatican City State (Holy See)" "Venezuela" "Vietnam" "Virgin Islands (British)" "Virgin Islands (U.S.)" "Wallis And Futuna Islands" "Western Sahara" "Yemen" "Yugoslavia" "Congo, The Democratic Republic Of The Zambia" "Zimbabwe" "Other Country"]
</div>
<div class="item ">
[textarea txtmessage class:membership]
</div>
<div class="item ">
[submit id:contact-submit class:button class:Subscribe class:Send "Submit"]
</div>
1
Contact Form Submission at MicroBiozIndia.Com
mailer@microbiozindia.com
kumar.microbioz@gmail.com
Name : [txtname]

Company Name : [txtcompanyname]

Email : [txtemail]

Mobile : [txtmobile]

Country : [country]

Message : [txtmessage]
Reply-To: [txtemail]












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