<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>
<div style="height:40px;"></div>
<div class="assessment-container container">
<div class="row">
<div class="col-md-6 form-box">
<form role="form" class="registration-form" action="javascript:void(0);">
<fieldset>
<div class="form-top">
<div class="form-top-left">
<h3><span><i class="fa fa-calendar-check-o" aria-hidden="true"></i></span>Lorem ipsum dolor sit amet</h3>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit
</p>
</div>
</div>
<div class="form-bottom">
<div class="row">
<div class="form-group col-md-6 col-sm-6">
<input type="text" class="form-control" placeholder="Firstname" id="fname">
</div>
<div class="form-group col-md-6 col-sm-6">
<input type="text" class="form-control" placeholder="Lastname" id="lname">
</div>
</div>
<div class="form-group" style="margin-bottom:3px;">
<div class="row">
<div class="form-group col-md-3 col-sm-3">
<select class="form-control">
<option>00</option>
<option>00</option>
<option>00</option>
<option>00</option>
<option>00</option>
</select>