<div class="request_callback_5">
    <div class="row">
        <div class="col-xs-12">
            <div class="input-group form-input">
                [email* your-email placeholder akismet:author_email "Your Email"]
            </div>
        </div>
        <div class="col-xs-12">
            <div class="input-group form-input">
                [text* free-link-address placeholder "Free Link Address"]
            </div>
        </div>
        <div class="col-xs-12">
            <div class="input-group form-input">
                [textarea* your-message placeholder "Your Message"]
            </div>
        </div>
        <div class="col-xs-12">
            <div class="input-group form-input">
                [recaptcha id:recaptcha]
            </div>
        </div>
        <div class="col-xs-12">
            <div class="input-group form-input">
                <button type="submit" class="button theme_style_3 size-lg icon_right vc_general vc_btn3 vc_btn3-size-xs vc_btn3-shape-rounded vc_btn3-style-modern vc_btn3-icon-right vc_btn3-color-info" style="font-size: 20px; font-weight: 500; padding-left: 50px; padding-right: 50px;">SUBMIT <i class="fa fa-chevron-right"></i></button>
            </div>
        </div>
    </div>
</div>