<div class="caption">~caption html~</div>
<div class="field"><select name="~name~"><option value="">Choose One:</option><!--~~~name~ states~~--></select></div><!--~}~--><!--~radio {~-->
<div class="caption">~caption html~</div>
<div class="caption">~caption html~</div>
<div class="field"><select name="~name~"><option value="">Choose One:</option><!--~~~name~ states~~--></select></div><!--~}~--><!--~radio {~-->
<div class="caption">~caption html~</div>
</div><!--~}~--><!--~checkbox {~-->
<div class="caption"><input type="checkbox" name="~name~~~~name~ checked~~" id="~name~_checkbox"><label for="~name~_checkbox"> ~caption html~</label></div>
<div class="field"></div><!--~}~--><!--~submit {~-->
</div><!--~}~--><!--~checkbox {~-->
<div class="caption"><input type="checkbox" name="~name~~~~name~ checked~~" id="~name~_checkbox"><label for="~name~_checkbox"> ~caption html~</label></div>
<div class="field"></div><!--~}~--><!--~submit {~-->