document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub13.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=1041286426&formid=4058&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:1041286426:13:4058\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>ご予約　英語力向上で見えてくる２つの世界</div></div> </div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">お名前（漢字） <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"苗字・お名前\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">お名前（カタカナ） <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-167893186181940\" placeholder=\"苗字・お名前\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Eメールアドレス <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-2\" placeholder=\"Eメールアドレス\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Eメールアドレス <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-167893192692397\" placeholder=\"Eメールアドレス\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\"> ご住所（都道府県/　市・街・区/　丁目までで結構です） <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1678931988322101\" placeholder=\"都道府県・市・街/区\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">電話番号（任意） </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-167893201736964\" placeholder=\"電話番号\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">ご職業 <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-167893204598673\" placeholder=\"ご職業\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><div class=\"bn-row\"><span class=\"bn-label\">ご年代 <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-select\"><select name=\"Field-1678932119267107[]\" required=\"required\"><option value=\"10代\" selected=\"\">10代</option><option value=\"20代\">20代</option><option value=\"30代\">30代</option><option value=\"40代\">40代</option><option value=\"50代\">50代</option><option value=\"60代\">60代</option><option value=\"70代\">70代</option><option value=\"80代+\">80代+</option></select></span></span></div></div><div class=\"fields-wrapper\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">今回の講演会は何でお知りになりましたか </span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"茅ヶ崎市の掲示板\"> <span class=\"bn-inner-label\">茅ヶ崎市の掲示板</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"茅ヶ崎市からのメール配信\"> <span class=\"bn-inner-label\">茅ヶ崎市からのメール配信</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"茅ヶ崎市の広報誌\"> <span class=\"bn-inner-label\">茅ヶ崎市の広報誌</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"セブンシーズのホームページ\"> <span class=\"bn-inner-label\">セブンシーズのホームページ</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"茅ヶ崎市公共の施設ーチラシを見て\"> <span class=\"bn-inner-label\">茅ヶ崎市公共の施設ーチラシを見て</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"茅ヶ崎市のホームページ\"> <span class=\"bn-inner-label\">茅ヶ崎市のホームページ</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"知人からの紹介\"> <span class=\"bn-inner-label\">知人からの紹介</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167893229181783[]\" value=\"他\"> <span class=\"bn-inner-label\">他</span></label></span></span></div></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\"> 上記の質問に「他」とお答えした方、よろしければどちらでお講演会のことをお知りになったかお知らせいただけませんでしょうか。 </span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"\" validator=\"\"></textarea></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">ご質問・ご感想 </span> <span class=\"bn-input\"><textarea name=\"Field-167893294616473\" placeholder=\"ご質問・ご感想\" validator=\"\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"\"> <input type=\"hidden\" name=\"thankyou\" value=\"\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"ご予約・お申し込みありがとうございました。\"> <input type=\"hidden\" name=\"subject\" value=\"予約：英語力向上で見えてくる2つの世界\"><div class=\"bn-form-submit\"><button type=\"submit\" class=\"formbtn\">送信</button></div> <style type=\"text/css\">.bnet-form ::-webkit-input-placeholder {');
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