<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 ----------> <div class="container"> <div class="col-xs-12 col-md-5"> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Form Name</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="address"></label> <div class="col-md-8"> <input id="address" name="address" type="text" placeholder="e.g. 2910 East 5th Street, Austin, TX 78702, USA" class="form-control input-md" required=""> <span class="help-block">Home, Destination, etc</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="age">Age</label> <div class="col-md-4"> <input id="age" name="age" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="income">Annual Income</label> <div class="col-md-4"> <input id="income" name="income" type="text" placeholder="e.g. 30000" class="form-control input-md"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="disabilty">Disabilty</label> <div class="col-md-4"> <select id="disabilty" name="disabilty" class="form-control"> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="wheelchair">Wheel Chair</label> <div class="col-md-4"> <select id="wheelchair" name="wheelchair" class="form-control"> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="medicaid">Medicaid</label> <div class="col-md-4"> <select id="medicaid" name="medicaid" class="form-control"> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="veteran">Veteran</label> <div class="col-md-4"> <select id="veteran" name="veteran" class="form-control"> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="household">Persons In Household</label> <div class="col-md-4"> <input id="household" name="household" type="text" placeholder="(Include Kids)" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="kids">Kids Under 18</label> <div class="col-md-4"> <input id="kids" name="kids" type="text" placeholder="(In Household)" class="form-control input-md"> </div> </div> <!-- Button (Double) --> <div class="form-group"> <label class="col-md-4 control-label" for="submit"></label> <div class="col-md-8"> <button id="submit" name="submit" class="btn btn-success">Submit</button> <button id="reset" name="reset" class="btn btn-default">reset</button> </div> </div> </fieldset> </form> </div> <div class="col-xs-12 col-md-7"> <div id="map">Map Here <div id="crosshair"></div> <div id="map_canvas" class="fullscreen"></div> </div> </div> </div>