<div class="form-flat">

<label>Nature of your Business : </label>
[radio nature-business default:0 "Wholesaler" "Manufacturer" "Retailer" "Others"]

<label>Please describe your specific/customized requirements:* </label>
[textarea* your-message] </p>

<label>Company-Name : </label>[text* your-name placeholder "Company-Name (required)"]
<label>Contact-Person : </label>[text* contact-person placeholder "Contact-Person (required)"]
<label>E-Mail : </label>[email* your-email placeholder "E-Mail (required)"]
<label>Mobile : </label>[tel* mobile placeholder "Mobile (required)"] 
<label>Phone : </label>[tel* phone placeholder "Phone (required)"]
<label>Fax: </label>[tel fax placeholder "Fax"]
<label>Street Address : </label>[text address placeholder "Street Address"]
<label>City/State : </label>[text city placeholder "City/State"]
<label>Zip/Postal Code : </label>[text zip placeholder "Zip/Postal Code"]
<label>Country : </label>[select Country data:countries]
</p>

[submit class:button primary "Submit"]
</div>