    <label>
        <input name="_mc4wp_lists[]" type="checkbox" value="acef23ad23" checked> <span>Procure General Newsletter</span>
    </label>
<p>  
</p>
<p>
	<label>Provide your email address: 
	<input type="email" name="EMAIL" placeholder="Your email address" required /></label>
</p>

<p>
	<input type="submit" value="Sign up" />
</p>