<script src="http://www.jotform.com/min/g=jotform&3.1.1" type="text/javascript"></script>
<script type="text/javascript">
JotForm.init();
</script>
<link type="text/css" rel="stylesheet" href="http://www.jotform.com/css/styles/form.css?v3"/>
<link href="http://www.jotform.com/css/calendarview.css" rel="stylesheet" type="text/css" />
<style type="text/css">
.form-label{
width:150px !important;
}
.form-label-left{
width:150px !important;
}
.form-line{
padding:10px;
}
.form-label-right{
width:150px !important;
}
.form-all{
width:690px;
color:Black !important;
font-family:Verdana;
font-size:12px;
}
</style>
<form class="jotform-form" action="http://www.jotform.com/submit.php" method="post" enctype="multipart/form-data" name="form_21903304722" id="21903304722" accept-charset="utf-8">
<input type="hidden" name="formID" value="21903304722" />
<div class="form-all">
<ul class="form-section">
<li class="form-line" id="id_1">
<label class="form-label-left" id="label_1" for="input_1">
आपका नाम:<span class="form-required">*</span>
</label>
<div id="id_1" class="form-input">
<input type="text" class="form-textbox validate[required, Alphabetic]" id="input_1" name="q1_1" size="20" />
</div>
</li>
<li class="form-line" id="id_5">
<label class="form-label-left" id="label_5" for="input_5">
ईमेल:<span class="form-required">*</span>
</label>
<div id="id_5" class="form-input">
<input type="text" class="form-textbox validate[required, Email]" id="input_5" name="q5_5" size="20" />
</div>
</li>
<li class="form-line" id="id_3">
<label class="form-label-left" id="label_3" for="input_3">
श्रेणी:<span class="form-required">*</span>
</label>
<div id="id_3" class="form-input">
<input type="text" class="form-textbox validate[required, Alphabetic]" id="input_3" name="q3_3" size="20" />
</div>
</li>
<li class="form-line" id="id_4">
<label class="form-label-left" id="label_4" for="input_4">
भेजे:<span class="form-required">*</span>
</label>
<div id="id_4" class="form-input">
<input class="form-upload validate[required]" type="file" name="q4_4" id="input_4" accept="pdf, doc, docx, txt, zip, mp3, avi, jpg, jpeg, png, gif" maxsize="1024" />
</div>
</li>
<li class="form-line" id="id_2">
<div id="id_2" class="form-input-wide">
<div style="margin-left:156px" class="form-buttons-wrapper">
<button id="input_2" type="submit" class="form-submit-button">
Submit Form
</button>
</div>
</div>
</li>
<li style="display:none">
Should be Empty:
<input type="text" name="website" value="" />
</li>
</ul>
</div>
<input type="hidden" id="simple_spc" name="simple_spc" value="21903304722" />
<script type="text/javascript">
document.getElementById("si" + "mple" + "_spc").value = "21903304722-21903304722";
</script>
</form>