<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 ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Données Personnelles</legend> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="selectbasic">Titre</label> <div class="col-md-4"> <select id="selectbasic" name="selectbasic" class="form-control"> <option value="1">Mademoiselle</option> <option value="2">Madame</option> <option value="3">Monsieur</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Nom22">Nom</label> <div class="col-md-4"> <input id="Nom22" name="Nom22" placeholder="Nom" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Prénom">Prénom</label> <div class="col-md-4"> <input id="Prénom" name="Prénom" placeholder="Prénom" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Ddn">Date de Naissance</label> <div class="col-md-4"> <input id="Ddn" name="Ddn" placeholder="Date de Naissance" class="form-control input-md" required="" type="text"> <span class="help-block">format :JJ/MM/YYYY</span> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="EtatC">Etat Civil</label> <div class="col-md-4"> <select id="EtatC" name="EtatC" class="form-control"> <option value="1">Marié(e)</option> <option value="2">Divorcé(e)</option> <option value="3">Séparé(e)</option> <option value="4">Célibataire</option> <option value="5">Veuf(ve)</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="rue">Adresse</label> <div class="col-md-4"> <input id="rue" name="rue" placeholder="Adresse" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="num">N°</label> <div class="col-md-1"> <input id="num" name="num" placeholder="N°" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="CP">Code Postal</label> <div class="col-md-2"> <input id="CP" name="CP" placeholder="Code Postal" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="commune">Commune</label> <div class="col-md-4"> <input id="commune" name="commune" placeholder="Commune" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="mail">Adresse e-mail</label> <div class="col-md-4"> <input id="mail" name="mail" placeholder="Adresse e-mail" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="tel">Téléphone</label> <div class="col-md-4"> <input id="tel" name="tel" placeholder="Téléphone" class="form-control input-md" required="" type="text"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="typeHypo">Objet du prêt Hypothécaire</label> <div class="col-md-4"> <select id="typeHypo" name="typeHypo" class="form-control"> <option value="1">Acquisition</option> <option value="2">Rénovation</option> <option value="3">Refinancement</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="revMensNet">Revenus mensuels nets</label> <div class="col-md-4"> <input id="revMensNet" name="revMensNet" placeholder="Revenus mensuels nets" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="revMensNetP">Revenus mensuels nets partenaire</label> <div class="col-md-4"> <input id="revMensNetP" name="revMensNetP" placeholder="Revenus mensuels nets partenaire" class="form-control input-md" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="montant">Montant</label> <div class="col-md-4"> <input id="montant" name="montant" placeholder="Montant" class="form-control input-md" required="" type="text"> </div> </div> <!-- Button --> <div class="form-group"> <label class="col-md-4 control-label" for="send">Envoyer Demande</label> <div class="col-md-4"> <button id="send" name="send" class="btn btn-primary">Envoyer</button> </div> </div> </fieldset> </form>