<fieldset>
    <legend>{REFERRER_LEGEND}</legend>
    <table class="formFields" cellspacing="0" width="100%">
        <tr {REFERRER_TYPE_ERROR}>
            <td class="name">{REFERRER_TYPE_TEXT}</td>
            <td>{REFERRER_TYPE}</td>
        </tr>
        <tr {REFERRER_ERROR}>
            <td class="name">{REFERRER_TEXT}&nbsp;{REQ}</td>
            <td><input type="text" name="referrer_custom" id="fid-referrer_custom" value="{REFERRER_VALUE}" size="20">&nbsp;<span class="hint">{REFERRER_HINT}</span></td>
        </tr>
    </table>
    <input type="hidden" name="referrer" value="{REFERRER_VALUE}">
</fieldset>
