{heading1:body}

    {infotype:body}

{text1:body}

{codes:body}
    {regions:body}
{additionalinfo:body}

{heading3:body}

{region:validation}
{region:body}
{organization:validation}
{organization:body}
{address1:validation}
{address1:body}
{address2:body}
{address3:body}
{city:body}
{state:body}
{province:body}
{zip:body}

{heading4:body}

{prefix:validation}
{prefix:body}
{firstname:validation}
{firstname:body}
{lastname:validation}
{lastname:body}
{jobtitle:validation}
{jobtitle:body}
{tel:validation}
{tel:body}
{companyemail:validation}
{companyemail:body}
{contact:body}
{message:body}
* Indicates required information
{captcha:body}
{submit:body} {clear-form:body}