<div  class="width100" style="width:60%; margin:0px auto; overflow:hidden;">
	<div  class="width100" style="width:50%; float:left; padding:5px;">
[text* Name class:new_input placeholder "Name"]
[text* Email class:new_input placeholder "Email"]
[text* Phone class:new_input placeholder "Phone"]
[text* contry_of_birth class:new_input placeholder "Country of Birth"]
	</div>
    <div class="width100" style="width:50%; float:left; padding:5px;">
[text* contry_of_citizen class:new_input placeholder "Country of citizenship"]
[textarea ReasonforRequestingaConsultation class:w_discription placeholder"Reason for a requesting a consultation"]
[text* how_did_you_hear class:new_input placeholder "How did you hear about us?"]
        
	</div>
[submit class:submit_new]
        <input type="radio" style="float:left;    margin: 4px 12px 0px 33px; color:#0c0a49;"><p  style=" color: #0c0a49; width: 195px; margin: 0px; float: left;">Suscribe to  our News letter</p>
</div>