diff --git a/apps/dashboard/src/@/actions/chain-integration-request.ts b/apps/dashboard/src/@/actions/chain-integration-request.ts
new file mode 100644
index 00000000000..56ebc95bc13
--- /dev/null
+++ b/apps/dashboard/src/@/actions/chain-integration-request.ts
@@ -0,0 +1,62 @@
+"use server";
+import "server-only";
+
+import { getAuthToken } from "@/api/auth-token";
+import { NEXT_PUBLIC_THIRDWEB_API_HOST } from "@/constants/public-envs";
+
+export type ChainIntegrationRequest = {
+  companyName: string;
+  telegram: string;
+  email: string;
+  chainName: string;
+  chainShortName: string;
+  chainId: string;
+  publicRpc: string;
+  iconUrl: string;
+  iconWidth: string;
+  iconHeight: string;
+  iconFormat: string;
+  nativeCurrencyName: string;
+  nativeCurrencySymbol: string;
+  nativeCurrencyDecimals: string;
+  blockExplorerUrl: string;
+  blockExplorerStandard: string;
+  explorerIconWidth: string;
+  explorerIconHeight: string;
+  explorerIconFormat: string;
+  faucetOrBridge: string;
+  chainStack?: string;
+};
+
+export async function submitChainIntegrationRequest(
+  request: ChainIntegrationRequest,
+): Promise<{ ok: true } | { ok: false; error: string }> {
+  const token = await getAuthToken();
+  if (!token) {
+    return { error: "You are not logged in", ok: false };
+  }
+
+  const res = await fetch(
+    new URL("/v1/chains/integration-requests", NEXT_PUBLIC_THIRDWEB_API_HOST),
+    {
+      body: JSON.stringify(request),
+      headers: {
+        Authorization: `Bearer ${token}`,
+        "Content-Type": "application/json",
+      },
+      method: "POST",
+    },
+  );
+
+  if (!res.ok) {
+    return {
+      error:
+        res.status === 429
+          ? "Too many requests, please try again in a minute"
+          : "Failed to submit request, please try again later",
+      ok: false,
+    };
+  }
+
+  return { ok: true };
+}
diff --git a/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/components/server/add-chain-button.tsx b/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/components/server/add-chain-button.tsx
index 5618eab206e..f27fc92dabf 100644
--- a/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/components/server/add-chain-button.tsx
+++ b/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/components/server/add-chain-button.tsx
@@ -7,7 +7,7 @@ export function AddYourChainButton(props: { className?: string }) {
     <Button asChild className={props.className} variant="default">
       <Link
         className="flex items-center gap-2"
-        href="https://share.hsforms.com/1XDi-ieM9Rl6oIkn7ynK6Lgea58c"
+        href="/chainlist/request"
         rel="noopener noreferrer"
         target="_blank"
       >
diff --git a/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/request/chain-integration-request-form.tsx b/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/request/chain-integration-request-form.tsx
new file mode 100644
index 00000000000..2f17ce1f066
--- /dev/null
+++ b/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/request/chain-integration-request-form.tsx
@@ -0,0 +1,245 @@
+"use client";
+
+import { zodResolver } from "@hookform/resolvers/zod";
+import { CheckCircle2Icon } from "lucide-react";
+import { useState } from "react";
+import { useForm } from "react-hook-form";
+import { toast } from "sonner";
+import { z } from "zod";
+import { submitChainIntegrationRequest } from "@/actions/chain-integration-request";
+import { Button } from "@/components/ui/button";
+import {
+  Form,
+  FormControl,
+  FormField,
+  FormItem,
+  FormLabel,
+  FormMessage,
+} from "@/components/ui/form";
+import { Input } from "@/components/ui/input";
+import {
+  Select,
+  SelectContent,
+  SelectItem,
+  SelectTrigger,
+  SelectValue,
+} from "@/components/ui/select";
+
+const CHAIN_STACKS = [
+  "Optimism",
+  "Arbitrum",
+  "Polygon AggLayer",
+  "zkSync",
+  "Avalanche",
+  "Fully custom Bespoke Chain",
+] as const;
+
+const text = (max = 300) =>
+  z.string().trim().min(1, "Required").max(max, "Too long");
+const digits = z
+  .string()
+  .trim()
+  .regex(/^[0-9]{1,20}$/, "Must be a number");
+
+const formSchema = z.object({
+  blockExplorerStandard: text(50),
+  blockExplorerUrl: text(2000),
+  chainId: digits,
+  chainName: text(),
+  chainShortName: text(50),
+  chainStack: z.enum(CHAIN_STACKS).optional(),
+  companyName: text(),
+  email: z.string().trim().email("Invalid email").max(254),
+  explorerIconFormat: text(20),
+  explorerIconHeight: digits,
+  explorerIconWidth: digits,
+  faucetOrBridge: text(2000),
+  iconFormat: text(20),
+  iconHeight: digits,
+  iconUrl: text(2000),
+  iconWidth: digits,
+  nativeCurrencyDecimals: digits,
+  nativeCurrencyName: text(),
+  nativeCurrencySymbol: text(20),
+  publicRpc: text(2000),
+  telegram: text(),
+});
+
+type FormValues = z.infer<typeof formSchema>;
+type TextFieldName = Exclude<keyof FormValues, "chainStack">;
+
+const SECTIONS: {
+  title: string;
+  fields: { name: TextFieldName; label: string; placeholder?: string }[];
+}[] = [
+  {
+    fields: [
+      { label: "Company name", name: "companyName" },
+      { label: "Telegram", name: "telegram" },
+      { label: "Email", name: "email" },
+    ],
+    title: "Contact",
+  },
+  {
+    fields: [
+      { label: "Chain Name", name: "chainName" },
+      { label: "Chain Short Name", name: "chainShortName", placeholder: "ETH" },
+      { label: "Chain Id", name: "chainId", placeholder: "1" },
+      { label: "Public RPC", name: "publicRpc" },
+      {
+        label:
+          "Icon URL (must be a publicly accessible/hosted link or IPFS URL)",
+        name: "iconUrl",
+        placeholder:
+          "ipfs://QmbYKZ1MuDa1hzwLGjdCZGapuhV7C9uyRDPJWD994qbocY/generic-icon.png",
+      },
+      { label: "Icon Width", name: "iconWidth", placeholder: "512" },
+      { label: "Icon Height", name: "iconHeight", placeholder: "512" },
+      { label: "Icon Format", name: "iconFormat", placeholder: "png" },
+    ],
+    title: "Mainnet Chain Info",
+  },
+  {
+    fields: [
+      {
+        label: "Native Currency",
+        name: "nativeCurrencyName",
+        placeholder: "Ether",
+      },
+      { label: "Symbol", name: "nativeCurrencySymbol", placeholder: "ETH" },
+      { label: "Decimals", name: "nativeCurrencyDecimals", placeholder: "18" },
+    ],
+    title: "Native Currency",
+  },
+  {
+    fields: [
+      {
+        label: "Block Explorer",
+        name: "blockExplorerUrl",
+        placeholder: "https://etherscan.io/",
+      },
+      {
+        label: "Chain Standard",
+        name: "blockExplorerStandard",
+        placeholder: "EIP3091",
+      },
+      {
+        label: "Explorer Icon Width",
+        name: "explorerIconWidth",
+        placeholder: "83",
+      },
+      {
+        label: "Explorer Icon Height",
+        name: "explorerIconHeight",
+        placeholder: "83",
+      },
+      {
+        label: "Explorer Icon Format",
+        name: "explorerIconFormat",
+        placeholder: "svg",
+      },
+      { label: "Faucet/Bridge", name: "faucetOrBridge" },
+    ],
+    title: "Block Explorer",
+  },
+];
+
+const defaultValues = Object.fromEntries(
+  SECTIONS.flatMap((section) => section.fields.map((f) => [f.name, ""])),
+) as Omit<FormValues, "chainStack">;
+
+export function ChainIntegrationRequestForm() {
+  const [submitted, setSubmitted] = useState(false);
+  const form = useForm<FormValues>({
+    defaultValues,
+    resolver: zodResolver(formSchema),
+  });
+
+  async function onSubmit(values: FormValues) {
+    const res = await submitChainIntegrationRequest(values);
+    if (!res.ok) {
+      toast.error(res.error);
+      return;
+    }
+    setSubmitted(true);
+  }
+
+  if (submitted) {
+    return (
+      <div className="flex items-center gap-3 rounded-lg border bg-card p-6">
+        <CheckCircle2Icon className="size-5 text-success-text" />
+        <p>Thank you for submitting your chain request!</p>
+      </div>
+    );
+  }
+
+  return (
+    <Form {...form}>
+      <form
+        className="flex flex-col gap-8"
+        onSubmit={form.handleSubmit(onSubmit)}
+      >
+        {SECTIONS.map((section) => (
+          <fieldset className="flex flex-col gap-4" key={section.title}>
+            <legend className="mb-4 font-semibold text-xl">
+              {section.title}
+            </legend>
+            {section.fields.map((f) => (
+              <FormField
+                control={form.control}
+                key={f.name}
+                name={f.name}
+                render={({ field }) => (
+                  <FormItem>
+                    <FormLabel>{f.label}</FormLabel>
+                    <FormControl>
+                      <Input
+                        className="bg-card"
+                        placeholder={f.placeholder}
+                        {...field}
+                      />
+                    </FormControl>
+                    <FormMessage />
+                  </FormItem>
+                )}
+              />
+            ))}
+          </fieldset>
+        ))}
+
+        <FormField
+          control={form.control}
+          name="chainStack"
+          render={({ field }) => (
+            <FormItem>
+              <FormLabel>Chain Stack</FormLabel>
+              <Select onValueChange={field.onChange} value={field.value}>
+                <FormControl>
+                  <SelectTrigger className="bg-card">
+                    <SelectValue placeholder="Please select" />
+                  </SelectTrigger>
+                </FormControl>
+                <SelectContent>
+                  {CHAIN_STACKS.map((stack) => (
+                    <SelectItem key={stack} value={stack}>
+                      {stack}
+                    </SelectItem>
+                  ))}
+                </SelectContent>
+              </Select>
+              <FormMessage />
+            </FormItem>
+          )}
+        />
+
+        <Button
+          className="w-fit"
+          disabled={form.formState.isSubmitting}
+          type="submit"
+        >
+          {form.formState.isSubmitting ? "Submitting..." : "Submit"}
+        </Button>
+      </form>
+    </Form>
+  );
+}
diff --git a/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/request/page.tsx b/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/request/page.tsx
new file mode 100644
index 00000000000..953a59caa94
--- /dev/null
+++ b/apps/dashboard/src/app/(app)/(dashboard)/(chain)/chainlist/request/page.tsx
@@ -0,0 +1,29 @@
+import type { Metadata } from "next";
+import { getAuthToken } from "@/api/auth-token";
+import { loginRedirect } from "@/utils/redirects";
+import { ChainIntegrationRequestForm } from "./chain-integration-request-form";
+
+export const metadata: Metadata = {
+  title: "Mainnet Chain Integration Request",
+};
+
+export default async function ChainIntegrationRequestPage() {
+  const authToken = await getAuthToken();
+  if (!authToken) {
+    loginRedirect("/chainlist/request");
+  }
+
+  return (
+    <section className="container mx-auto flex max-w-2xl flex-col px-4 py-10">
+      <h1 className="font-semibold text-3xl tracking-tight">
+        Mainnet Chain Integration Request
+      </h1>
+      <p className="mt-2 text-muted-foreground">
+        Share your chain details and our team will get back to you.
+      </p>
+      <div className="mt-8">
+        <ChainIntegrationRequestForm />
+      </div>
+    </section>
+  );
+}
diff --git a/apps/dashboard/src/app/(app)/team/[team_slug]/(team)/~/infrastructure/deploy/page.tsx b/apps/dashboard/src/app/(app)/team/[team_slug]/(team)/~/infrastructure/deploy/page.tsx
index c4294402cdc..0e915c1c5c4 100644
--- a/apps/dashboard/src/app/(app)/team/[team_slug]/(team)/~/infrastructure/deploy/page.tsx
+++ b/apps/dashboard/src/app/(app)/team/[team_slug]/(team)/~/infrastructure/deploy/page.tsx
@@ -106,7 +106,7 @@ export default function DeployInfrastructurePage() {
                     Share your chain details via{" "}
                     <a
                       className="underline underline-offset-4"
-                      href="https://share.hsforms.com/1XDi-ieM9Rl6oIkn7ynK6Lgea58c"
+                      href="/chainlist/request"
                       rel="noopener noreferrer"
                       target="_blank"
                     >