<form class="list">

        <ul>

          

          <li class="item-content item-input">

            <div class="item-inner">

              <div class="item-title item-label">Email</div>

              <div class="item-input-wrap">

                <input name="email_4" type="text" disabled placeholder="Email">

              </div>

            </div>

          </li>

          <li class="item-content item-input">

            <div class="item-inner">

              <div class="item-title item-label">Reason</div>

              <div class="item-input-wrap">

                <textarea id="reason_4" placeholder="Reason"></textarea>

              </div>

            </div>

          </li>

          

        </ul>

      <div class="separator-medium"></div>

          <div class="container">

            <button id="account_delete_button" class="btn btn-primary btn-block fw-700">Delete Account</button>

          </div>

      </form>