<p>Full Name (required)<br />
    [text* your-name] </p>

<p>Your Email (required)<br />
    [email* your-email] </p>

<p>Address (required)<br /><p>
[text* address]</p>

<p>City (required)<br /><p>
[text* city]</p>

<p>State (required)<br /><p>
[text* state]</p>

<p>Zip Code (required)<br /><p>
[text* zip]</p>

<p>Country (required)<br /><p>
[text* country]</p>

<p>Phone (required)<br /><p>
[text* phone]</p>

<p>[submit "Submit"]</p>