"Registro Libre"
Bootstrap 3.2.0 Snippet by gmaccarone

<link href="//netdna.bootstrapcdn.com/bootstrap/3.2.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.2.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <link href="//maxcdn.bootstrapcdn.com/font-awesome/4.1.0/css/font-awesome.min.css" rel="stylesheet"> <div id="login-overlay" class="modal-dialog"> <div class="modal-content"> <div class="modal-header"> <button type="button" class="close" data-dismiss="modal"><span aria-hidden="true">×</span><span class="sr-only">Close</span></button> <h1 class="modal-title" id="myModalLabel">Staff Empresarial Latinoamerica</h1> <h2 class="modal-title" id="myModalLabel">Registro Gratis</h2> </div> <div class="modal-body"> <div class="row"> <div class="col-xs-6"> <div class="well"> <form id="loginForm" method="POST" action="http://qt.net.ve/sistema/prospecto.php" novalidate="novalidate"> <div class="form-group"> <label for="username" class="control-label">Nombre</label> <input type="text" class="form-control" id="nombre" name="nombre" value="" required="" title="Introduzca su nombre" placeholder="Juan Perez"> <span class="help-block"></span> </div> <div class="form-group"> <label for="correo" class="control-label">Correo</label> <input type="text" class="form-control" id="correo" name="correo" value="" required="" title="Correo electrónico"> <span class="help-block"></span> </div> <div class="form-group"> <label for="Empresa" class="control-label">Empresa</label> <input type="text" class="form-control" id="empresa" name="empresa" value="" required="" title="Nombre de su empresa" placeholder="Comercial Perez, S.A"> <span class="help-block"></span> </div> <div class="form-group"> <label for="celular" class="control-label">Celular</label> <input type="text" class="form-control" id="celular" name="celular" value="" required="" title="Número de Teléfono Celular con código de país" placeholder="58 424 9118177"> <span class="help-block"></span> </div> <div class="form-group"> <label for="País" class="control-label">País</label> <input type="text" class="form-control" id="pais" name="pais" value="" required="" title="País"> <span class="help-block"></span> </div> <div class="form-group"> <input type="submit" class="btn btn-info btn-block" id="registrar" name="registrar" value="Registrar"> </div> </form> </div> </div> <div class="col-xs-6"> <p class="lead">Registrese ahora para <span class="text-success">GRATIS</span></p> <ul class="list-unstyled" style="line-height: 2"> <li><span class="fa fa-check text-success"></span> Recibir 15 SMS </li> <li><span class="fa fa-check text-success"></span> Recibir 50 e-mail </li> <li><span class="fa fa-check text-success"></span> Afiliarse en Staff Empresarial LATAM</li> <li><span class="fa fa-check text-success"></span> Recibir 50 Contactos de su País</li> </ul> </div> </div> </div> </div> </div>

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