<div class="kargo_form_row">
<label> Country or Territory* 
    [select* menu-778 "United States " "Canada " "South America" "Africa"] 
</label>
</div>
<div class="kargo_form_row">
  <label> Company Name*
      [text* company-name] 
  </label> 
  <label> Contact
      [text contact] 
  </label>
</div>
<div class="kargo_form_row">
<label> Address*
    [text* street-address placeholder "Street Address"]</label>
</div>
<div class="kargo_form_row">
    [text address placeholder " Apartment, suite, unit, building, floor, etc."]
</div>
<div class="kargo_form_row">
    [text address placeholder "Department, c/o, etc."]
</div>
<div class="kargo_form_row">
<label> Zip Code*
    [text* zip-code] </label>
<label> City*
    [text city] </label>
<label> State*
    [select* menu-396 "Select One " "Alaska " "Alabama" "New York " "Texas " "California " "Virginia " "Washington"] </label>
</div>
<div class="kargo_form_row">
<label> E-mail*
    [email* my-email] </label>
<label> Telephone*
    [text* telephone] </label>
<label> Ext.
    [text ext] </label>
</div>

[checkbox checkbox-748 "Send updates on this shipment"] 

[wpgdprc "By using this form you agree with the storage and handling of your data by this website."]

[submit "Continue"]