<div class="request_callback">
    <div class="row">
        <div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
            <div class="input-group">
                [textarea* message placeholder "Your Message *"]
            </div>
        </div>
        <div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
            <div class="input-group">
                [text* text-name placeholder akismet:author "First name *"]
            </div>
        </div>
        <div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
            <div class="input-group">
                [email* email placeholder akismet:author_email "E-mail *"]
            </div>
        </div>
        <div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
            <div class="input-group">
                [text* subject placeholder "Subject *"]
            </div>
        </div>
        <div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
            <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>