_includes/templates/contact-form-band.html

<div class="component-wrapper contact-form-band">
  <div class="width-12-12">
    <h3>Receive enterprise support</h3>
    <form action="" class="grid-wrapper">
      <input type="text" id="fname" name="firstname" placeholder="Name" class="width-6-12" required>
      <input type="text" id="lname" name="lastname" placeholder="Last Name" class="width-6-12" required>
      <input type="email" id="email" name="email" placeholder="Email" class="width-6-12 width-12-12-m" required>
      <input type="tel" id="phone" name="telephone" placeholder="Telephone" class="width-6-12">
      <input type="text" id="company" name="company" placeholder="Company" class="width-4-12 width-6-12-m">
      <input type="text" id="country" name="country" placeholder="Country" class="width-4-12 width-6-12-m">
      <input type="text" id="state" name="state" placeholder="State / Province" class="width-4-12 width-6-12-m">
      <textarea id="subject" name="subject" placeholder="Aditional information or questions" class="width-12-12"></textarea>
      <input type="submit" value="Submit" class="width-6-12">
    </form>
  </div>
</div>
</div>