<div class="row form-djv-contact">
	<div class="col-sm-12" style="padding: 6px;">
		[text* your-name placeholder "Name"]
	</div>
	<div class="col-sm-12" style="padding: 6px;">
		[email* your-email placeholder "Email"]
	</div>
        <div class="col-sm-12" style="padding: 6px;">
		[text* your-company placeholder "Phone Number"]
	</div>
        <div class="col-sm-12" style="padding: 6px;">
		[text* your-phone placeholder "Occupation"]
	</div>
        <div class="col-sm-12" style="padding: 6px;">
		[select* Test first_as_label "Select Donation Amount" "$50" "$100" "$200" "$500"]
	</div>
        <div style="width:100%; text-align: center; padding: 6px 6px 0 6px;">
		[submit class:btn class:btn-rounded class:skin-primary class:travel-submit "Donate Now"]
        </div>
</div>