First Name
Last Name
Email Address
Phone Number
Country of Residence [radio* country class:form-control "United States" "Canada" "Mexico" "Other"]
Address
Address Line 2
City
State or Province Abbreviation
Postal Code
Message Subject [radio* subject class:form-control "Inquiry" "Praise" "Suggestion" "Concern"]
Message
Purchase Location [radio* location class:form-control "United States" "Canada" "Mexico" "Other"]
Product Name
UPC Number
"Best By" Date
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