<p>First Name (required):
[text* firstname]</p>

<p>Last Name (required): 
[text* lastname]</p>

<p>Address: 
[text address]</p>

<p>City: 
[text city]</p>

<p>State:
[text state]</p>

<p>Postal Code: 
[text postalcode]</p>

<p>Country: 
[text country]</p>

<p>Phone: 
[text phone]</p>

<p>Email: 
[email* email]

<p>Your Prayer Request (required)<br />
[textarea* praisereport]</p>

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