"Customer Registration"
Bootstrap 3.3.0 Snippet by MoteBiang

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<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <html> <title>SIM Resgistration and Activation - Telikom PNG</title> <body> <form class="form-horizontal" action="<?php echo $_SERVER['PHP_SELF']; ?>" method="post"> <fieldset> <!-- Form Name --> <legend>SIM Resgistration and Activation</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">MSISDN</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="msisdn" class="form-control input-md" required=""> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Name</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="your name" class="form-control input-md" required=""> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Surname</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="your surname" class="form-control input-md" required=""> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Nationality</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="your nationality" class="form-control input-md" required=""> <span class="help-block">help</span> </div> </div> <!-- Multiple Radios --> <div class="form-group"> <label class="col-md-4 control-label" for="radios">Gender</label> <div class="col-md-4"> <div class="radio"> <label for="radios-0"> <input type="radio" name="radios" id="radios-0" value="1" checked="checked"> Male </label> </div> <div class="radio"> <label for="radios-1"> <input type="radio" name="radios" id="radios-1" value="0"> Female </label> </div> </div> </div> <!-- Button --> <div class="form-group"> <label class="col-md-4 control-label" for="singlebutton"></label> <div class="col-md-4"> <button id="singlebutton" name="singlebutton" class="btn btn-primary">Activate</button> </div> </div> </fieldset> </form> </body> </html>

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