From: [required-email]
To: bathgoodies@theprizefairy.com
Subject:  Bath Goodies Giveaway

Name:            [required-realname]
Email Address:   [required-email]
Address:         [required-street]
City:            [required-city]
State:           [required-state]
Zip Code:        [required-zip]
Phone:           [required-phone]
Birth Date:      [required-dob]
Comments:        [comments] 

[$REMOTE_ADDR]