<p>Your name (*)<br />
    [text* your-name] </p>

<p>Your job title<br />
    [text your-title] </p>

<p>Company name<br />
    [text your-company] </p>

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

<p>Your phone number<br />
    [text your-phone] </p>

<p>Tell us what you are looking for?<br />
    [textarea your-message] </p>

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