<div class="discount">

[text* first-name class:form-control placeholder "First name"]

[text* last-name class:form-control placeholder "Last name"]

[email* your-email class:form-control placeholder "Email address (We'll never share your email with anyone else.)"]

[date date class:form-control placeholder "DOB"]
<div class="agre">

[acceptance acceptance class:form-control optional] Please be reassured that your information will not be passed onto third parties. Click <a href="https://wp.localserverweb.com/liberty/terms-conditions/" style="color: #d6b7b5;">here</a> for
the T&C's on our ‘Liberty VIP Club’. Your 10% discount code can only be used once and is
unique. It is not transferable even in the event of a cancellation, return, or replacement, so
please choose wisely. Check your email NOW – If you cannot see it, check out your junk folder.[/acceptance]

</div>
[submit class:btn class:bttn "Submit"]            
</div>