<div class="member_feedback">
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[text* text-name placeholder akismet:author "First Name"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[text* text-name2 placeholder akismet:author "Last Name"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[email* text-email placeholder akismet:author_email "E-mail"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[tel text-phone placeholder "Phone Number"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[text* text-city placeholder "City"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[select text-state first_as_label "Select State (USA only)" "Value 1" "Value 2"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
[select text-country first_as_label "Country" "Value 1" "Value 2"]
<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
<div class="input-group">
<button type="submit" class="button size-lg icon_left"><i class="fa fa-chevron-right"></i> submit</button>