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<p>
	<label>Email address: </label>
	<input type="email" name="EMAIL" placeholder="Your email address" required />
</p>
<p>
    <label>First Name</label>
    <input type="text" name="FNAME" required="">
</p>
<p>
    <label>Last Name</label>
    <input type="text" name="LNAME" required="">
</p>
<p>
    <label>Message</label>
    <input type="text" name="MMERGE6" required="">
</p>
<p>
    <label>Sign up for mailing list</label>
    <label>
        <input name="_mc4wp_action" type="radio" value="subscribe" required=""
        checked="true"> <span>Subscribe</span>
    </label>
    <label>
        <input name="_mc4wp_action" type="radio" value="unsubscribe" required=""> <span>Unsubscribe</span>
    </label>
</p>
<p>
    <input type="submit" value="Submit">
</p>