[md-form]

[md-text label="Name"]

[/md-text]

[md-text label="Contact number"]

[/md-text]

[md-text label="Email address"]

[/md-text]

[md-select label="State of Residence" tabletwidth="4" desktopwidth="6"]
—Please choose an option—NSWVICACTNTQLDSATASWATravel Agents
[/md-select]

[md-textarea label="Your message"]

[/md-textarea]

[md-submit]

[/md-submit]

[/md-form]