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=4073&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:1041286426:13:4073\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>ご予約　英語力向上のカギはあなたの一歩の勇気</div></div> </div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">お名前（漢字） </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"苗字・名前\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">お名前（カタカナ） </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-168623012261561\" placeholder=\"苗字・名前\" validator=\"\" 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=\"Email\" 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（ご確認のため） </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-168623017347367\" placeholder=\"Email\" validator=\"\" 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・区までで結構です） <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-168623025982887\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">電話番号 </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-168623027569054\" 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> <span class=\"bn-input\"><input type=\"text\" name=\"Field-168623029321739\" placeholder=\"ご職業\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><div class=\"bn-row\"><span class=\"bn-label\">ご年代 </span> <span class=\"bn-input\"><span class=\"bn-select\"><select name=\"Field-168623037727797[]\"><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\">この講演会はどこでお知りになりましたか　（複数回答可） </span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168623056603949[]\" value=\"茅ヶ崎市掲示板\"> <span class=\"bn-inner-label\">茅ヶ崎市掲示板</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168623056603949[]\" 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-168623056603949[]\" value=\"茅ヶ崎市広報誌\"> <span class=\"bn-inner-label\">茅ヶ崎市広報誌</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168623056603949[]\" 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-168623056603949[]\" 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-168623056603949[]\" 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-168623056603949[]\" value=\"茅ヶ崎市掲示板\"> <span class=\"bn-inner-label\">茅ヶ崎市掲示板</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168623056603949[]\" value=\"知人の紹介\"> <span class=\"bn-inner-label\">知人の紹介</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168623056603949[]\" value=\"セブンシーズからのメール配信\"> <span class=\"bn-inner-label\">セブンシーズからのメール配信</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168623056603949[]\" value=\"SENSEI イベントポータル\"> <span class=\"bn-inner-label\">SENSEI 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