[radio gender default:1 “先生” “小姐”]

姓氏*

[text* lastname]

名字*

<[text* surname]/td>

電郵

<[email* email]/td>

聯絡電話

<[tel tel]/td>

留言性質[checkbox checkbox-251 “評語／表揚” “投訴” “查詢” “就業” “其他”] [textarea* message] [submit “Send”]