<div id="premium-form">
<p>Civilité<br />
    [text* your-civ default:user_civ] </p>

<p>Nom<br />
    [text* your-name default:user_last_name] </p>


<p>Prénom<br />
    [text* your-first-name default:user_first_name] </p>

<p>Votre email <br />
    [email* your-email default:user_email] </p>


<p>Information(s) complémentaire(s)<br />
    [textarea your-message] </p>

<p>[submit "Envoyer"]</p>
</div>