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<form action="https://app.cyberimpact.com/optin" method="post" accept-charset="utf-8"><!-- [et_pb_line_break_holder] --> <fieldset><!-- [et_pb_line_break_holder] --> <legend></legend><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <label for="ci_firstname">First name :</label><!-- [et_pb_line_break_holder] --> <input type="text" id="ci_firstname" name="ci_firstname" maxlength="255" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <label for="ci_lastname">Last name :</label><!-- [et_pb_line_break_holder] --> <input type="text" id="ci_lastname" name="ci_lastname" maxlength="255" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <label for="ci_email">Email :</label><!-- [et_pb_line_break_holder] --> <input type="text" id="ci_email" name="ci_email" maxlength="255" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div style="display:block; visibility:hidden; height:1px;"><!-- [et_pb_line_break_holder] --> <input style="display:none;" type="text" id="ci_verification" name="ci_verification" /><!-- [et_pb_line_break_holder] --> <input type="hidden" id="ci_groups" name="ci_groups" value="2" /><!-- [et_pb_line_break_holder] --> <input type="hidden" id="ci_account" name="ci_account" value="e33faab7-d666-4234-ddf9-0b28cfba429d" /><!-- [et_pb_line_break_holder] --> <input type="hidden" id="ci_language" name="ci_language" value="en_ca" /><!-- [et_pb_line_break_holder] --> <input type="hidden" id="ci_sent_url" name="ci_sent_url" value="" /><!-- [et_pb_line_break_holder] --> <input type="hidden" id="ci_error_url" name="ci_error_url" value="" /><!-- [et_pb_line_break_holder] --> <input type="hidden" id="ci_confirm_url" name="ci_confirm_url" value="" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <input type="submit" value="Send" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div style="color:#aaa; font-size:10px;"><a style="color:#aaa; font-size:10px;text-decoration:none;" href="https://www.cyberimpact.com">Email marketing</a> <a style="color:#aaa; font-size:10px;text-decoration:none;" href="https://www.cyberimpact.com">Cyberimpact</a></div><!-- [et_pb_line_break_holder] --> </fieldset><!-- [et_pb_line_break_holder] --></form>

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