<div class="col1">
<p>Your Name (required)<br />
    [text* your-name] </p>

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

<p>Company<br />
    [text company] </p>
<p>[captchac captcha-547 size:s]
type the characters in the image above</p>
<p>[captchar captcha-547]</p>
<p>[submit "Send"]</p>
</div>