<div class="request_callback">
    <div class="row">
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [select* bueiness first_as_label "Business type *" "Agency" "Company/Enterprise" "Small business" "entrepreneur"]
            </div>
            <div class="input-group">
                [text* text-fname placeholder "First name *"]
            </div>
            <div class="input-group">
                [text* text-lname placeholder "Last Name *"]
            </div>
            <div class="input-group">
                [text* company placeholder "Company *"]
            </div>
            <div class="input-group">
                [text* title placeholder "Title *"]
            </div>
            <div class="input-group">
                [email* email placeholder "E-mail *"]
            </div>
            <div class="input-group">
                [tel* phone placeholder "Phone *"]
            </div>
            <div class="input-group">
                [select* country first_as_label "Country *" "Afghanistan" "Albania" "Algeria" "American Samoa" "Andorra" "Angola" "Anguilla" "Antigua and Barbuda" "Argentina" "Armenia" "Armenia" "Aruba" "Australia" "Austria" "Azerbaijan" "Azerbaijan" "Bahamas" "Bahrain" "Bangladesh" "Barbados" "Belarus" "Belgium" "Belize" "Benin" "Bermuda" "Bhutan" "Bolivia" "Bonaire" "Bosnia and Herzegovina" "Botswana" "Bouvet Island (Bouvetoya)" "Brazil" "British Indian Ocean Territory (Chagos Archipelago)" "British Virgin Islands" "Brunei Darussalam" "Bulgaria" "Burkina Faso" "Burundi" "Canada" "Cambodia" "Cameroon" "Cape Verde" "Cayman Islands" "Central African Republic" "Chad" "Chile" "China" "Christmas Island" "Cocos (Keeling) Islands" "Colombia" "Comoros" "Congo" "Congo" "Cook Islands" "Costa Rica" "Cote d'Ivoire" "Croatia" "Cuba" "Cura├ºao" "Cyprus" "Cyprus" "Czech Republic" "Denmark" "Djibouti" "Dominica" "Dominican Republic" "Ecuador" "Egypt" "El Salvador" "Equatorial Guinea" "Eritrea" "Estonia" "Ethiopia" "Falkland Islands (Malvinas)" "Faroe Islands" "Fiji" "Finland" "France" "French Guiana" "French Polynesia" "French Southern Territories" "Gabon" "Gambia" "Georgia" "Georgia" "Germany" "Ghana" "Gibraltar" "Greece" "Greenland" "Grenada" "Guadeloupe" "Guam" "Guatemala" "Guernsey" "Guinea" "Guinea-Bissau" "Guyana" "Haiti" "Heard Island and McDonald Islands" "Holy See (Vatican City State)" "Honduras" "Hong Kong" "Hungary" "Iceland" "India" "Indonesia" "Iran" "Iraq" "Ireland" "Isle of Man" "Israel" "Italy" "Jamaica" "Japan" "Jersey" "Jordan" "Kazakhstan" "Kazakhstan" "Kenya" "Kiribati" "Korea" "Korea" "Kuwait" "Kyrgyz Republic" "Lao People's Democratic Republic" "Latvia" "Lebanon" "Lesotho" "Liberia" "Libyan Arab Jamahiriya" "Liechtenstein" "Lithuania" "Luxembourg" "Macao" "Macedonia" "Madagascar" "Malawi" "Malaysia" "Maldives" "Mali" "Malta" "Marshall Islands" "Martinique" "Mauritania" "Mauritius" "Mayotte" "Mexico" "Micronesia" "Moldova" "Monaco" "Mongolia" "Montenegro" "Montserrat" "Morocco" "Mozambique" "Myanmar" "Namibia" "Nauru" "Nepal" "Netherlands" "Netherlands Antilles" "New Caledonia" "New Zealand" "Nicaragua" "Niger" "Nigeria" "Niue" "Norfolk Island" "Northern Mariana Islands" "Norway" "Oman" "Pakistan" "Palau" "Palestinian Territory" "Panama" "Papua New Guinea" "Paraguay" "Peru" "Philippines" "Pitcairn Islands" "Poland" "Portugal" "Puerto Rico" "Qatar" "Reunion" "Romania" "Russian Federation" "Rwanda" "Saint Barthelemy" "Saint Helena" "Saint Kitts and Nevis" "Saint Lucia" "Saint Martin" "Saint Pierre and Miquelon" "Saint Vincent and the Grenadines" "Samoa" "San Marino" "Sao Tome and Principe" "Saudi Arabia" "Senegal" "Serbia" "Seychelles" "Sierra Leone" "Singapore" "Sint Maarten (Netherlands)" "Slovakia (Slovak Republic)" "Slovenia" "Solomon Islands" "Somalia" "South Africa" "South Georgia & S. Sandwich Islands" "Spain" "Sri Lanka" "Sudan" "Suriname" "Svalbard & Jan Mayen Islands" "Swaziland" "Sweden" "Switzerland" "Syrian Arab Republic" "Taiwan" "Tajikistan" "Tanzania" "Thailand" "Timor-Leste" "Togo" "Tokelau" "Tonga" "Trinidad and Tobago" "Tunisia" "Turkey" "Turkey" "Turkmenistan" "Turks and Caicos Islands" "Tuvalu" "U.S. Virgin Islands" "U.S. Minor Outlying Islands" "Uganda" "Ukraine" "United Arab Emirates" "United Kingdom" "United States" "Uruguay" "Uzbekistan" "Vanuatu" "Venezuela" "Vietnam" "Wallis and Futuna" "Western Sahara" "Yemen" "Zambia" "Zimbabwe"]
            </div>
        </div>
        <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
            <div class="input-group">
                [textarea* message placeholder "Your Message *"]
            </div>
            <div class="input-group">
                [file file-252 limit:10000000 id:quote_file]
            </div>
            <div class="input-group">
               [recaptcha id:captcha]
            </div>
            <div class="input-group">
                <button type="submit" class="button size-lg icon_right">Submit <i class="fa fa-chevron-right"></i></button>
            </div>
        </div>
    </div>
</div>