[one_half][text* nam placeholder "Your Name"][/one_half] [one_half_last][tel* tel placeholder "Contact Number"][/one_half_last]

[one_half][date* date placeholder "Enter Date"][/one_half] [one_half_last][text* time placeholder "Enter Time in AM / PM"][/one_half_last]

[one_half][text namr "Desired Mode of Video Call"][/one_half] [one_half_last]  [/one_half_last]

[one_third] [checkbox checkbox-1 "Whatsapp"][/one_third] [one_third] [checkbox checkbox-2 "Google Duo"][/one_third] [one_third_last] [checkbox checkbox-3 "Skype"][/one_third_last]

[one_third] [checkbox checkbox-4 "Facebook"][/one_third] [one_third] [checkbox checkbox-5 "JusTalk"][/one_third] [one_third_last] [checkbox checkbox-6 "LINE"][/one_third_last]

[one_third] [checkbox checkbox-7 "Viber"][/one_third] [one_third] [checkbox checkbox-8 "WeChat"][/one_third] [one_third_last] [checkbox checkbox-9 "Yahoo"][/one_third_last]

[one_half][text textarea-6 placeholder "Additional Information"][/one_half] [one_half_last] [/one_half_last]

[submit "Send your request"]