Purple_Envelop_Order_Site/app/views/RequestOrder/index.asp

<section style="padding: 48px 0; max-width: 640px; margin: 0 auto;">
  <div class="section-heading">
    <span class="eyebrow">Start your order</span>
    <h1>Request an order</h1>
    <p>
      Enter your email address and jurisdiction number below. We'll email you a
      secure link to continue your order.
    </p>
  </div>

  <form method="post" action="<%= H(Routes().AppURL & "request-order") %>">
    <input type="hidden" name="csrf_token" value="<%= H(csrfToken) %>" />

    <div class="form-group" style="margin-bottom: 16px;">
      <label for="Email">Email address</label>
      <input type="email" class="form-control" id="Email" name="Email" required
             value="<%= H(emailValue) %>" />
    </div>

    <div class="form-group" style="margin-bottom: 24px;">
      <label for="JurisdictionNumber">Jurisdiction number</label>
      <input type="text" class="form-control" id="JurisdictionNumber" name="JurisdictionNumber" required
             value="<%= H(jurisdictionValue) %>" />
    </div>

    <button type="submit" class="button button-primary">Request order</button>
  </form>
</section>