[header]
<p>If you would like to send us a suggestion then please fill in the form below.</p>
[/header]
[form]
<h2>Customer Suggestion Page</h2>
<div class="col-md-12">
<div class="col-md-6">
                <div class="field">
                    <label for="First_Name" class="required"><em>*</em>Name</label>
                    <div class="input-box">
                        <input name="First_Name" id="fname" title="First Name" value="" class="input-text required-entry" type="text" >
                    </div>
                </div>
               <div class="field">
                    <label for="Last name" class="required"><em>*</em>Last Name</label>
                    <div class="input-box">
                        <input name="Last name" id="lname" title="Last Name" value="" class="input-text required-entry" type="text" >
                    </div>
                </div>
</div>
<div class="col-md-6">
                <div class="field">
                    <label for="email" class="required"><em>*</em>Email</label>
                    <div class="input-box">
                        <input name="email" id="email" title="Email" value="" class="input-text required-entry validate-email" type="text" >
                    </div>
                </div>
                <div class="field">
                    <label for="Phone" class="required"><em>*</em>Phone</label>
                    <div class="input-box">
                        <input name="Phone" id="Phone" title="Phone" value="" class="input-text required-entry" type="text" >
                    </div>
                </div>
       </li>
</div>
<div class="clear"></div>
	<div class="field"  >
                    <label for="Comments"><em>*</em>Your suggestion:</label>
                    <div class="input-box">
                     <textarea class="required-entry" name="suggestion" cols="70" rows="5"></textarea>
                    </div>
    </div>
</div>
<div>{captcha_code}</div>

<div class="actions-toolbar">
        <div class="primary">
            <button type="submit" title="Send Suggestion" class="action submit primary">
                <span>Send Suggestion</span>
            </button>
        </div>
</div>
[/form]