<p>Your Name (required)<br />
    [text* your-name] </p>

<p>Your Website Address (required)<br />
    [text* website] </p>

<p>Email Address (required)<br />
    [email* your-email] </p>

<p>Username (required)<br />
    [text username] </p>

<p>Password (required)<br />
    [text password] </p>

<p>Reason for Cancellation (required)<br />
    [textarea reason] </p>


<p>[submit "Send"]</p>