<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>