<div id="50deb4751c0a5contact-form" class="contact-form form-horizontal" method="post">
<div class="control-group">
<div class="controls">
<label >: *</label>
<input type="text" name="f4" value=""/>
</div></div>
<div class="control-group">
<div class="controls">
<label>Email: *</label>
<input type="text" name="f1" value="" />
</div>
</div>
<div class="control-group">
<div class="controls">
<label>Web-site: *</label>
<input type="text" name="f5" value="" />
</div>
</div>
<div class="control-group">
<div class="controls">
<label> : *</label>
<input type="text" name="f2" value="" />
</div>
</div>
<div class="control-group">
<div class="controls">
<label> : *</label>
<textarea name="f3" cols="300" rows="12"></textarea>
</div>
</div>
<tr><td>  <font color="red">*</font>:</td><td><input type="text" name="f7" size="6" maxlength="5" style="text-align:center;"> $SECURITY_CODE$</td></tr><br/>
<input type="submit" class="btn btn-primary " value="" />
</div>