A Form with "Any-of-Eight" Choices

Some text here describing products and services.  Some text here describing products and services.  Some text here describing products and services.  Some text here describing products and services.  Some text here describing products and services.  Some text here describing products and services.  Some text here describing products and services.  

 

Please provide the following information:
Name
Telephone
E-mail
I am interested in more information about:
(Choose one or more of the following)
Choice One Choice Two
Choice Three Choice Four
Choice Five Choice Six
Choice Seven Choice Eight

LOGO GOES HERE