Here it is:
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<style>
.link,
.signupframe {
color: #2F2929;
font-family: Arial, Helvetica, sans-serif;
}
.link {
text-decoration: none;
}
.signupframe {
border: 1px solid #1010CD;
background: #ffffff;
}
</style>
<form method=post action="https://app.icontact.com/icp/signup.php" name="icpsignup" accept-charset="UTF-8" onsubmit="return verifyRequired();" >
<input type=hidden name=redirect value="http://www.icontact.com/www/signup/thanks.html" />
<input type=hidden name=errorredirect value="http://www.icontact.com/www/signup/error.html" />
<script type="text/javascript">
if (document.location.protocol === "https:")
document.icpsignup.action = "https://app.icontact.com/icp/signup.php";
function verifyRequired() {
if (document.icpsignup["fields_email"].value == "") {
document.icpsignup["fields_email"].focus();
alert("The Email field is required.");
return false;
}
if (document.icpsignup["fields_fname"].value == "") {
document.icpsignup["fields_fname"].focus();
alert("The First Name field is required.");
return false;
}
if (document.icpsignup["fields_lname"].value == "") {
document.icpsignup["fields_lname"].focus();
alert("The Last Name field is required.");
return false;
}
return true;
}
</script>
<div id="SignUp">
<table width="260" class="signupframe" border="0" cellspacing="0" cellpadding="5">
<tr>
<td valign=top align=right>
<font size="1" face="Arial,Helvetica, sans-serif">*</font> <font size="2">Email</font>
</td>
<td align=left>
<input type=text name="fields_email">
</td>
</tr>
<td valign=top align=right>
<font size="1" face="Arial,Helvetica, sans-serif">*</font> <font size="2">First Name</font>
</td>
<td align=left>
<input type=text name="fields_fname">
</td>
</tr>
<td valign=top align=right>
<font size="1" face="Arial,Helvetica, sans-serif">*</font> <font size="2">Last Name</font>
</td>
<td align=left>
<input type=text name="fields_lname">
</td>
</tr>
<input type=hidden name="listid" value="9866575">
<input type=hidden name="specialid:9866575" value="GTL1">
<input type=hidden name=clientid value="406779">
<input type=hidden name=formid value="3476">
<input type=hidden name=reallistid value="1">
<input type=hidden name=doubleopt value="0">
<TR>
<TD> </TD>
<TD><font size="1">*</font><font size="2"> = Required Field</FONT></TD>
</TR>
<tr>
<td> </td>
<td><input type="submit" name="Submit" value="Submit"></td>
</tr>
</table>
</div>
</form>
<a class="link" href="http://www.icontact.com"><font size="2">Email Marketing You Can Trust</font></a>