Your information:

Name: {Name (First):6.3} {Name (Last):6.6}
Email: {Email:8}
Phone: {Phone:10}

Address: {Address (Street Address):7.1} {Address (Address Line 2):7.2} | {Address (City):7.3}, {Address (State / Province):7.4} {Address (ZIP / Postal Code):7.5}
User IP Address: {ip}

I am interested in all of the following:
{I am interested in all of the following (select one or more):24}

Questions, Comments and Feedback:
{Questions, Comments and Feedback:26}