<fieldset>
    <legend>Receive Your Visitors Guide</legend>
    <fieldset>
        <legend>Contact Details</legend>
        <p>[text* your-name placeholder "Your Name * "]</p>
        <p>[text your-org placeholder "Organization"]</p>
        <p>[text* your-address1 placeholder "Address 1 * "]</p>
        <p>[text your-address2 placeholder "Address 2 "]</p>
        <p>[text* your-city placeholder "City * "]</p>
        <p>[select* your-state "AL" "AK" "AS" "AZ" "AR" "CA" "CO" "CT" "DE" "DC" "FM" "FL" "GA" "GU" "HI" "ID" "IL" "IN" "IA" "KS" "KY" "LA" "ME" "MH" "MD" "MA" "MI" "MN" "MS" "MO" "MT" "NE" "NV" "NH" "NJ" "NM" "NY" "NC" "ND" "MP" "OH" "OK" "OR" "PW" "PA" "PR" "RI" "SC" "SD" "TN" "TX" "UT" "VT" "VI" "VA" "WA" "WV" "WI" "WY"]</p>
        <p>[tel* your-phone placeholder "Postal Code * "]</p>
        <p>[email* your-email placeholder "Email * "]</p>
        <p>[date* travel-date]</p>
    </fieldset>
    <fieldset>
        <legend>More Information Available</legend>
        <p>[checkbox more-information "Group Tour Planning" "Meeting Planner" "Relocation/Real Estate"]</p>
    </fieldset>
    <fieldset>
        <legend>Which Best Describes You?</legend>
        <p>[checkbox describe-you "Individual" "Group Tour Planning" "Relocation/Real Estate"]</p>
    </fieldset>
    <fieldset>
        <legend>Choose Things That interest You</legend>
        <fieldset>
            <legend>Lodging</legend>
            <p>[checkbox your-interests "Individual" "Group Tour Planning" "Relocation/Real Estate"]</p>
        </fieldset>
        <fieldset>
            <legend>Attractions</legend>
            <p>[checkbox attractions "State Park" "Coal Mining" "Historic Sites" "Train Excursions " "Theatre" "New River Gorge" "Fairs & Festivals" "Dining " "Shopping"]</p>
        </fieldset>
        <fieldset>
            <legend>Recreation</legend>
            <p>[checkbox recreation "Rafting" "Skiing " "Golf" "Hiking" "Rock Climbing" "Hunting/Fishing" "Horseback Riding" "Caving" "Kayaking/Canoe" "Biking" "ATV Trails" "Motorcycle Touring"]</p>
        </fieldset>
    </fieldset>
    <p>[select referral "Internet Search" "Radio" "Television" "Washington Post" "Reader's Digest" "Woman's Day" "WV State Guide" "Let's Golf" "Better Homes and Gardens" "Family Circle" "Good Housekeeping" "OH Long Weekends" "AAA Tour Book" "Ladies Home Journal" "Blue Ridge Country" "Oprah Magazine" "American Motorcyclist" "Guest Quest" "Southern Living" "Girlfriend Getaway" "American Iron" "Redbook" "See Ya There" "Rejuvenate Magazine" "Group Tour Planet" "Destinations Magazine" "Recreation News" "Other"]</p>
    <p>[textarea your-questions Placeholder "Questions, comments..."]</p>
<p>[captchac captcha-550]</p>
<p>[captchar captcha-550]</p>
</fieldset>