<div class="row">
    [hidden page-title id:ct7-page-title]
    [hidden page-url id:ct7-page-url]
                            <div class="input-outer col-md-6">
                               [text your-name placeholder "Name"]
                            </div>
                            <div class="input-outer col-md-6">
                               [tel* telephone-no placeholder "Telephone no"]
                            </div>
                        </div>

                        <div class="row">
                            <div class="input-outer col-md-6">
                                [text address placeholder "House number &amp; Street name"]
                            </div>
                            <div class="input-outer col-md-6">
                                [text city placeholder "City"]
                            </div>
                        </div>
                        <div class="row">
                            <div class="input-outer col-md-6">
                                [text nic placeholder "NIC"]
                            </div>
                            <div class="input-outer col-md-6">
[select description-of-article "Chain/Necklace" "Bracelet/Bangle" "Earing" "Coin" "Other"]
                            </div>
                        </div>

                        <div class="row">
                            <div class="input-outer col-md-12 pb-3 pt-2">
                                <p>Options of Service</p>
                            </div>
                            <div class="input-outer col-md-12">
                                <div class="radio">
                                    [radio service-type use_label_element default:1 "Home Pick Up" "Visit Local Branch"]
                                  
                                  </div>
                            </div>
                           
                        </div>
                       
                        <div class="action pt-4">
                           [submit class:contact-btn class:text-uppercase "Submit request"]
                        </div>