<p><br /><span class="contentheading">Free Trial </span><br /><br /><img src="images/free_trial.jpg" border="0" align="right" /></p>
<div style="float:left">
<div class="form_item">
<div class="form_element cf_textbox"><label class="cf_label" style="width: 100px;">Name</label> {text_0}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_textbox"><label class="cf_label" style="width: 100px;">Address</label> {text_1}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_textbox"><label class="cf_label" style="width: 100px;">City</label> {text_9}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_textbox"><label class="cf_label" style="width: 100px;">Postal Code</label> {text_5}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_textbox"><label class="cf_label" style="width: 100px;">Phone</label> {text_6}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_textbox"><label class="cf_label" style="width: 100px;">Email</label> {text_4}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_dropdown"><label class="cf_label" style="width: 100px;">Location</label> {select_10}</div>
<div class="clear"> </div>
</div>
<!--
<div class="form_item">
<div class="form_element cf_datetimepicker"><label class="cf_label" style="width: 80px;">Preferred Date</label> {date_9}</div>
-->
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_textarea"><label class="cf_label" style="width: 100px;">Comments</label> {text_8}</div>
<div class="clear"> </div>
</div>
<div class="form_item">
<div class="form_element cf_button">{This_element_has_no_name_attribute}</div>
<div class="clear"> </div>
</div>