gistfile1.txt

<form action="action_page.php" method="post" name="theform" class="form" id="forma">

							<div class="item">
								<p><span>*</span> Your name:</p>
								<input type="text" name="Your Name" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Debt problem:</p>
								<input type="text" name="Debt Problem" value="" class="width input-first-name validate[required]">
							</div>

							<div class="item">
								<p>Your contact details</p>
							</div>

							<div class="item">
								<p><span>*</span> Work:</p>
								<input type="text" name="Work Phone" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Home:</p>
								<input type="text" name="Home Phone" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p>Fax:</p>
								<input type="text" name="Fax" value="">
							</div>

							<div class="item">
								<p><span>*</span> Mobile:</p>
								<input type="text" name="Mobile" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Your email:</p>
								<input class="width input-first-name validate[required]" type="text" name="email" id="email" />
							</div>

							<div class="item">
								<p><span>*</span> Debt $</p>
								<input type="text" name="Debt" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Debtor's name:</p>
								<input type="text" name="Debtor_name" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Debtor's current address:</p>
								<input type="text" name="Debtor_current_address" value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Debt outstanding since:</p>
								<input type="text" name="Debt_outstanding_since: " value="" class="input-first-name validate[required]">
							</div>

							<div class="item">
								<p><span>*</span> Debt incurred for (job/services/goods):</p>
								<br>
								<input type="text" name="venue" value="" class="width input-first-name validate[required]">
							</div>

							<div class="item">
								<br>
								<span class="required">*Required Fields</span>
							</div>

							<div class="captsha">
								<p>Enter the code shown in the image:</p>
								<br>
								<input type="text" class="input-first-name validate[required]">
								<br><br>
							</div>

							<img src="img/captsha.gif" alt="">

							<div class="col-12 cf form-buttons">
								<button type="reset">Reset</button>
								<input type="submit" value="Submit">
							</div>

						</form>