Warranty Data Form

<!-- Begin MailChimp Signup Form -->
<div id="mc_embed_signup">
<form action="https://brellabrella.us16.list-manage.com/subscribe/post?u=73d2ea4dda18db7b2601b12bb&amp;id=c99d978860" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate>
<div id="mc_embed_signup_scroll">
<h2>Subscribe to our mailing list</h2>
<div class="indicates-required"><span class="asterisk">*</span> indicates required</div>
<div class="mc-field-group">
<label for="mce-EMAIL">Email Address <span class="asterisk">*</span>
</label>
<input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL">
</div>
<div class="mc-field-group">
<label for="mce-FNAME">First Name </label>
<input type="text" value="" name="FNAME" class="" id="mce-FNAME">
</div>
<div class="mc-field-group">
<label for="mce-LNAME">Last Name </label>
<input type="text" value="" name="LNAME" class="" id="mce-LNAME">
</div>
<div class="mc-field-group">
<label for="mce-MMERGE3">Company </label>
<input type="text" value="" name="MMERGE3" class="" id="mce-MMERGE3">
</div>
<div class="mc-address-group">
<div class="mc-field-group">
<label for="mce-MMERGE6-addr1">Address </label>
<input type="text" value="" maxlength="70" name="MMERGE6[addr1]" id="mce-MMERGE6-addr1" class="">
</div>
<div class="mc-field-group">
<label for="mce-MMERGE6-addr2">Address Line 2</label>
<input type="text" value="" maxlength="70" name="MMERGE6[addr2]" id="mce-MMERGE6-addr2">
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE6-city">City</label>
<input type="text" value="" maxlength="40" name="MMERGE6[city]" id="mce-MMERGE6-city" class="">
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE6-state">State/Province/Region</label>
<input type="text" value="" maxlength="20" name="MMERGE6[state]" id="mce-MMERGE6-state" class="">
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE6-zip">Postal / Zip Code</label>
<input type="text" value="" maxlength="10" name="MMERGE6[zip]" id="mce-MMERGE6-zip" class="">
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE6-country">Country</label>
<select name="MMERGE6[country]" id="mce-MMERGE6-country" class=""><option value="164" selected>USA</option><option value="286">Aaland Islands</option><option value="274">Afghanistan</option><option value="2">Albania</option><option value="3">Algeria</option><option value="178">American Samoa</option><option value="4">Andorra</option><option value="5">Angola</option><option value="176">Anguilla</option><option value="175">Antigua And Barbuda</option><option value="6">Argentina</option><option value="7">Armenia</option><option value="179">Aruba</option><option value="8">Australia</option><option value="9">Austria</option><option value="10">Azerbaijan</option><option value="11">Bahamas</option><option value="12">Bahrain</option><option value="13">Bangladesh</option><option value="14">Barbados</option><option value="15">Belarus</option><option value="16">Belgium</option><option value="17">Belize</option><option value="18">Benin</option><option value="19">Bermuda</option><option value="20">Bhutan</option><option value="21">Bolivia</option><option value="325">Bonaire, Saint Eustatius and Saba</option><option value="22">Bosnia and Herzegovina</option><option value="23">Botswana</option><option value="181">Bouvet Island</option><option value="24">Brazil</option><option value="180">Brunei Darussalam</option><option value="25">Bulgaria</option><option value="26">Burkina Faso</option><option value="27">Burundi</option><option value="28">Cambodia</option><option value="29">Cameroon</option><option value="30">Canada</option><option value="31">Cape Verde</option><option value="32">Cayman Islands</option><option value="33">Central African Republic</option><option value="34">Chad</option><option value="35">Chile</option><option value="36">China</option><option value="185">Christmas Island</option><option value="37">Colombia</option><option value="204">Comoros</option><option value="38">Congo</option><option value="183">Cook Islands</option><option value="268">Costa Rica</option><option value="275">Cote D'Ivoire</option><option value="40">Croatia</option><option value="276">Cuba</option><option value="298">Curacao</option><option value="41">Cyprus</option><option value="42">Czech Republic</option><option value="318">Democratic Republic of the Congo</option><option value="43">Denmark</option><option value="44">Djibouti</option><option value="289">Dominica</option><option value="187">Dominican Republic</option><option value="45">Ecuador</option><option value="46">Egypt</option><option value="47">El Salvador</option><option value="48">Equatorial Guinea</option><option value="49">Eritrea</option><option value="50">Estonia</option><option value="51">Ethiopia</option><option value="189">Falkland Islands</option><option value="191">Faroe Islands</option><option value="52">Fiji</option><option value="53">Finland</option><option value="54">France</option><option value="193">French Guiana</option><option value="277">French Polynesia</option><option value="56">Gabon</option><option value="57">Gambia</option><option value="58">Georgia</option><option value="59">Germany</option><option value="60">Ghana</option><option value="194">Gibraltar</option><option value="61">Greece</option><option value="195">Greenland</option><option value="192">Grenada</option><option value="196">Guadeloupe</option><option value="62">Guam</option><option value="198">Guatemala</option><option value="270">Guernsey</option><option value="63">Guinea</option><option value="65">Guyana</option><option value="200">Haiti</option><option value="66">Honduras</option><option value="67">Hong Kong</option><option value="68">Hungary</option><option value="69">Iceland</option><option value="70">India</option><option value="71">Indonesia</option><option value="278">Iran</option><option value="279">Iraq</option><option value="74">Ireland</option><option value="323">Isle of Man</option><option value="75">Israel</option><option value="76">Italy</option><option value="202">Jamaica</option><option value="78">Japan</option><option value="288">Jersey (Channel Islands)</option><option value="79">Jordan</option><option value="80">Kazakhstan</option><option value="81">Kenya</option><option value="203">Kiribati</option><option value="82">Kuwait</option><option value="83">Kyrgyzstan</option><option value="84">Lao People's Democratic Republic</option><option value="85">Latvia</option><option value="86">Lebanon</option><option value="87">Lesotho</option><option value="88">Liberia</option><option value="281">Libya</option><option value="90">Liechtenstein</option><option value="91">Lithuania</option><option value="92">Luxembourg</option><option value="208">Macau</option><option value="93">Macedonia</option><option value="94">Madagascar</option><option value="95">Malawi</option><option value="96">Malaysia</option><option value="97">Maldives</option><option value="98">Mali</option><option value="99">Malta</option><option value="207">Marshall Islands</option><option value="210">Martinique</option><option value="100">Mauritania</option><option value="212">Mauritius</option><option value="241">Mayotte</option><option value="101">Mexico</option><option value="102">Moldova, Republic of</option><option value="103">Monaco</option><option value="104">Mongolia</option><option value="290">Montenegro</option><option value="294">Montserrat</option><option value="105">Morocco</option><option value="106">Mozambique</option><option value="242">Myanmar</option><option value="107">Namibia</option><option value="108">Nepal</option><option value="109">Netherlands</option><option value="110">Netherlands Antilles</option><option value="213">New Caledonia</option><option value="111">New Zealand</option><option value="112">Nicaragua</option><option value="113">Niger</option><option value="114">Nigeria</option><option value="217">Niue</option><option value="214">Norfolk Island</option><option value="272">North Korea</option><option value="116">Norway</option><option value="117">Oman</option><option value="118">Pakistan</option><option value="222">Palau</option><option value="282">Palestine</option><option value="119">Panama</option><option value="219">Papua New Guinea</option><option value="120">Paraguay</option><option value="121">Peru</option><option value="122">Philippines</option><option value="221">Pitcairn</option><option value="123">Poland</option><option value="124">Portugal</option><option value="126">Qatar</option><option value="315">Republic of Kosovo</option><option value="127">Reunion</option><option value="128">Romania</option><option value="129">Russia</option><option value="130">Rwanda</option><option value="205">Saint Kitts and Nevis</option><option value="206">Saint Lucia</option><option value="324">Saint Martin</option><option value="237">Saint Vincent and the Grenadines</option><option value="132">Samoa (Independent)</option><option value="227">San Marino</option><option value="255">Sao Tome and Principe</option><option value="133">Saudi Arabia</option><option value="134">Senegal</option><option value="326">Serbia</option><option value="135">Seychelles</option><option value="136">Sierra Leone</option><option value="137">Singapore</option><option value="302">Sint Maarten</option><option value="138">Slovakia</option><option value="139">Slovenia</option><option value="223">Solomon Islands</option><option value="140">Somalia</option><option value="141">South Africa</option><option value="257">South Georgia and the South Sandwich Islands</option><option value="142">South Korea</option><option value="311">South Sudan</option><option value="143">Spain</option><option value="144">Sri Lanka</option><option value="293">Sudan</option><option value="146">Suriname</option><option value="225">Svalbard and Jan Mayen Islands</option><option value="147">Swaziland</option><option value="148">Sweden</option><option value="149">Switzerland</option><option value="285">Syria</option><option value="152">Taiwan</option><option value="260">Tajikistan</option><option value="153">Tanzania</option><option value="154">Thailand</option><option value="233">Timor-Leste</option><option value="155">Togo</option><option value="232">Tonga</option><option value="234">Trinidad and Tobago</option><option value="156">Tunisia</option><option value="157">Turkey</option><option value="158">Turkmenistan</option><option value="287">Turks &amp; Caicos Islands</option><option value="159">Uganda</option><option value="161">Ukraine</option><option value="162">United Arab Emirates</option><option value="262">United Kingdom</option><option value="163">Uruguay</option><option value="165">Uzbekistan</option><option value="239">Vanuatu</option><option value="166">Vatican City State (Holy See)</option><option value="167">Venezuela</option><option value="168">Vietnam</option><option value="169">Virgin Islands (British)</option><option value="238">Virgin Islands (U.S.)</option><option value="188">Western Sahara</option><option value="170">Yemen</option><option value="173">Zambia</option><option value="174">Zimbabwe</option></select>
</div>
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE4">Phone Number </label>
<input type="text" name="MMERGE4" class="" value="" id="mce-MMERGE4">
</div>
<div class="mc-field-group">
<label for="mce-MMERGE11">Product Purchased </label>
<select name="MMERGE11" class="" id="mce-MMERGE11">
<option value=""></option>
<option value="The Brella 1010">The Brella 1010</option>

</select>
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE7-month">Date of Purchase <span class="asterisk">*</span>
</label>
<div class="datefield">
<span class="subfield monthfield"><input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="MM" size="2" maxlength="2" name="MMERGE7[month]" id="mce-MMERGE7-month"></span> /
<span class="subfield dayfield"><input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="MMERGE7[day]" id="mce-MMERGE7-day"></span> /
<span class="subfield yearfield"><input class="datepart required" type="text" pattern="[0-9]*" value="" placeholder="YYYY" size="4" maxlength="4" name="MMERGE7[year]" id="mce-MMERGE7-year"></span>
<span class="small-meta nowrap">( mm / dd / yyyy )</span>
</div>
</div>
<div class="mc-field-group">
<label for="mce-MMERGE8">Where was Product Purchased <span class="asterisk">*</span>
</label>
<select name="MMERGE8" class="required" id="mce-MMERGE8">
<option value=""></option>
<option value="Brella Brella web site">Brella Brella web site</option>
<option value="Amazon">Amazon</option>
<option value="Fishing Retailer">Fishing Retailer</option>
<option value="Golf Retailer">Golf Retailer</option>
<option value="Outdoor Sports Retailer">Outdoor Sports Retailer</option>
<option value="Other Retailer">Other Retailer</option>

</select>
</div>
<div class="mc-field-group size1of2">
<label for="mce-MMERGE9">Amount you paid for the Product <span class="asterisk">*</span>
</label>
<input type="number" name="MMERGE9" class="required" value="" id="mce-MMERGE9">
</div>
<div class="mc-field-group input-group">
<strong>Email Format </strong>
<ul><li><input type="radio" value="html" name="EMAILTYPE" id="mce-EMAILTYPE-0"><label for="mce-EMAILTYPE-0">html</label></li>
<li><input type="radio" value="text" name="EMAILTYPE" id="mce-EMAILTYPE-1"><label for="mce-EMAILTYPE-1">text</label></li>
</ul>
</div>
<div id="mce-responses" class="clear">
<div class="response" id="mce-error-response" style="display:none"></div>
<div class="response" id="mce-success-response" style="display:none"></div>
</div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups-->
<div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_73d2ea4dda18db7b2601b12bb_c99d978860" tabindex="-1" value=""></div>
<div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div>
</div>
</form>
</div>

<!--End mc_embed_signup-->