<article class="box story">
<div class="box_in">
<h4 class="title h1">Обратная связь</h4>
<div class="addform">
<ul class="ui-form">
<li class="form-group combo">
<div class="combo_field"><input placeholder="Ваше имя" type="text" maxlength="35" name="f4" id="name" class="wide" required></div>
<div class="combo_field"><input placeholder="Ваш E-mail" type="email" maxlength="35" name="f1" id="email" class="wide" required></div>
</li>

<li class="form-group"><input placeholder="Тема сообщения" type="text" maxlength="45" name="f2" id="subject" class="wide" required></li>
<li class="form-group"><textarea placeholder="Сообщение" name="f3" id="message" rows="8" class="wide" required></textarea></li>
<li class="form-group">$SECURITY_CODE$</li>
</ul>

<div class="form_submit"><button class="btn btn-big" type="submit" name="send_btn"><b>Отправить сообщение</b></button></div>
</div>
</div>
</article>