<div class="col span_6">
<p>Name <span>*</span><br />
    [text* full-name] </p>
</div>
<div class="col span_6 col_last">
<p>Email Address <span>*</span><br />
    [email* your-email] </p>
</div>
<div class="col span_6">
<p>Phone Number<br />
    [tel tel-528]</p>
</div>
<div class="col span_6 col_last">
<p>Where Are You Based <span>*</span><br />
    [text* country-name]</p>
</div>
<div class="col span_12">
<p>Message<br />
    [textarea your-message] </p></div>
<div class="col span_12">
[checkbox* checkbox-737 "I agree to the Terms and Conditions."]
</div>
 <div class="col span_12"><p>[submit "Submit"]</p></div>