[label name=”name” label=”Name *”][/label] [su_row] [su_column size=”1/2″] [field_input name=”firstname” type=”name” label=”First” req=”required”][/field_input] [/su_column] [su_column size=”1/2″] [field_input name=”lastname” type=”name” label=”Last”][/field_input] [/su_column] [/su_row] [su_row] [field_input name=”email” type=”email” label=”Email *”][/field_input] [/su_row][su_row] [su_column size=”1/2″] [field_input name=”day_time_phone” type=”phone” label=”Day Time Phone”][/field_input] [/su_column] [su_column size=”1/2″] [field_input name=”night_time_phone” type=”phone” label=”Night Time Phone”][/field_input] [/su_column] [/su_row]
[su_row] [label name=”address” label=”Address”][/label] [/su_row] [su_row] [field_input name=”street_address” type=”address” label=”Street Address”][/field_input] [/su_row] [su_row] [field_input name=”address_line2″ type=”address” label=”Address Line 2″][/field_input] [/su_row]
[su_row] [su_column size=”1/2″] [field_input name=”city” type=”address” label=”City”][/field_input] [/su_column] [su_column size=”1/2″] [field_input name=”state/province/region” type=”address” label=”State/Province/Region”][/field_input] [/su_column] [/su_row]
[su_row] [su_column size=”1/2″] [field_input name=”postal/zip_code” type=”address” label=”Postal / Zip Code”][/field_input] [/su_column] [su_column size=”1/2″] [field_country size=”50″][/field_country] [/su_column] [/su_row]
[label name=”label” label=”Is it alright if we send you email updates? You may withdraw your consent at any time.”][/label] [su_row] [su_column size=”1/6″] [field_bullet name=”email_updates” type=”bullet” label=” Yes”][/field_bullet] [/su_column] [su_column size=”1/6″] [field_bullet name=”email_updates” type=”bullet” label=” No”][/field_bullet] [/su_column] [su_column size=”1/6″] [/su_column] [/su_row]
[su_row] [/su_row]