<div id="email-form-container">
<form id="email-form" action="http://ciudadano2cero.us2.list-manage.com/subscribe/post" method="POST">
<input name="u" value="73c6ab78e2e697ada9b992316" type="hidden">
<input name="id" value="ceee3326cb" type="hidden">
<div id="form-fields">
<div id="mergeRow-1">
<label for="MERGE1">
<strong>Nombre, sin apellidos</strong>
<span class="mandatory">(*)</span>
</label>
<div>
<input name="MERGE1" id="MERGE1" size="25" value="" type="text">
</div>
</div>
<div id="mergeRow-0">
<label for="MERGE0">
<strong>Correo electrónico</strong>
<span class="mandatory">(*)</span>
</label>
<div>
<input autocapitalize="off" autocorrect="off" name="MERGE0" id="MERGE0" size="25" value="" type="email">
</div>
</div>
</div>
<div id="submit-button">
<input alt="suscribirme" src="http://ciudadano2cero.com/wp-custom/widgets/subscribeWidget/images/send-button.png" name="submit" type="image">
</div>
</form>
</div>