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      [text* your-name placeholder "Full Name"]
      [email
      your-email placeholder "Email Address"]
      [tel
      MobileNumber placeholder "Mobile Number"]
      [select
      NearestOffice "Select Nearest Office" "Kathmandu" "Pokhara" "Butwal" "Birtamode" "Bhairahawa" "Parsa" "Nawalparasi" "Chitwan" "Sydney"]
      [select
      Preferredstudydestination "Select Preferred Study Destination" "Australia" "New Zealand" "Canada" "UK" "USA" "Ireland"]
      [checkbox
      checkbox-29 use_label_element "Yes, I would like to receive information on study abroad news and events from TheNext."]

      [submit "Submit"]