<div class="black-box post-comment">
<div class="black-box-content">
<h2>Bel mij terug</h2>
<p>Laat uw gegevens achter en u wordt binnen 3 dagen teruggebeld.</p>
<div>
<input type="radio" name="mv" value="Heer" />Heer
<input type="radio" name="mv" value="Mevrouw" />Mevrouw
<input type="text" id="voorletter" name="Voorletter" placeholder="Voorletter" >
<input type="text" id="achternaam" name="achternaam" placeholder="Achternaam" >
<input type="text" id="email" name="email" placeholder="Postcode" >
<input type="text" id="email" name="email" placeholder="Huisnummer" >
<input type="text" id="email" name="email" placeholder="Telefoon" >
<div class="form-cancel">
<a href="index.html" data-transition="flip" class=''>
<img src="images/cancel.png" alt="icon">
<span>Terug</span>
<div class="clear"></div>
</a>
</div>
<!-- Big Red Button -->
<div class="btn-big btn-red form-submit">
<a href="#" data-transition="flip" class=''>
<div class="btn-pattern">
<span>Bel mij terug</span>
</div>
</a>
</div>
<!-- END: Big Red Button -->
<div class="clear"></div>
</div>
</div>
</div>