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<div class="fieldset fieldset--phone">
      <label class="image-replace lrm-email lrm-ficon-phone" title="phone*"></label>
      <input name="phone" class="full-width has-padding has-border" type="text" placeholder="lrm-ficon-phone*" required="">
      <span class="lrm-error-message"></span>
</div>

<div class="fieldset fieldset--location">
      <label class="image-replace lrm-email lrm-ficon-location" title=""></label>
      <input name="location" class="full-width has-padding has-border" type="text" placeholder=".lrm-ficon-location" required="">
      <span class="lrm-error-message"></span>
</div>

<div class="fieldset fieldset--map">
      <label class="image-replace lrm-email lrm-ficon-map" title=""></label>
      <input name="address1" class="full-width has-padding has-border" type="text" placeholder=".lrm-ficon-map" required="">
      <span class="lrm-error-message"></span>
</div>

<div class="fieldset fieldset--compass">
      <label class="image-replace lrm-email lrm-ficon-compass" title=""></label>
      <input name="address2" class="full-width has-padding has-border" type="text" placeholder=".lrm-ficon-compass" required="">
      <span class="lrm-error-message"></span>
</div>

<div class="fieldset fieldset--mobile-phone">
      <label class="image-replace lrm-email lrm-ficon-mobile-phone" title=""></label>
      <input name="mobile" class="full-width has-padding has-border" type="text" placeholder=".lrm-ficon-mobile-phone" required="">
      <span class="lrm-error-message"></span>
</div>