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<div style="font:bold 14px Tahoma, Geneva, sans-serif; color:#d60000;">Обратная связь</div>


<form method="post" style="padding:0; margin:0;">




 

<div style="padding:9px 5px; font:normal 12px Tahoma, Geneva, sans-serif; color:#000;">Ваше имя или название организации:</div><div style="background:url(/t/v35/images/pop_input.gif) top left no-repeat; width:251px; height:25px;"><input style="background:none; padding:0 5px; border:0; line-height:25px; height:25px; width:251px;" type="text" size="30" maxlength="100" value="" name="d[0]" id="d[0]" /></div>



 

<div style="padding:9px 5px; font:normal 12px Tahoma, Geneva, sans-serif; color:#000;">Ваш E-mail или телефон:</div><div style="background:url(/t/v35/images/pop_input.gif) top left no-repeat; width:251px; height:25px;"><input style="background:none; padding:0 5px; border:0; line-height:25px; height:25px; width:251px;" type="text" size="30" maxlength="100" value="" name="d[1]" id="d[1]" /></div>



 
<b>Текст:</b><SPAN style="color:red">*</SPAN><br /><TEXTAREA cols="50" rows="7" name="d[2]" id="d[2]"></TEXTAREA>






 

<style>img.captcha {
border:1px solid gray;
}</style>

<br />

<img class="captcha" src=".gif" align="left" hspace="5"><div style="font:normal 13px/16px Tahoma, Geneva, sans-serif; color:#d60000;">Каждому подписчику Суперскидка</div>
<input type="text" size="5" maxlength="4" name="_cn" style="border:1px solid #808080; width:90px; height:15px; line-height:15px; margin:1px 0 0 0;">

<input type="hidden" value="" name="_cs" />


<br>

<input type="submit" value="Отправить" style="background:url(/t/v35/images/pop_button.gif) bottom repeat-x; padding:0; height:27px; width:94px; color:#fff; font:normal 12px/27px Tahoma, Geneva, sans-serif; margin:20px 0 0 0; border:none;cursor:pointer; text-align:center; *float:left;" />
<span style="background:url(/t/v35/images/pop_button.gif) bottom repeat-x; padding:0; height:27px; width:94px; color:#fff; font:normal 12px/27px Tahoma, Geneva, sans-serif; margin:19px 0 0 28px; border:none;cursor:pointer; text-align:center; display:inline-block" onclick="close_form()">Отмена</span>

<re-captcha data-captcha="recaptcha"
     data-name="captcha"
     data-sitekey="6LcYvrMcAAAAAKyGWWuW4bP1De41Cn7t3mIjHyNN"
     data-lang="ru"
     data-rsize="invisible"
     data-type="image"
     data-theme="light"></re-captcha></form>



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