<link href="//netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/css/bootstrap-combined.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/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>SOLICITUD EXAMENES MEDICOS</legend> <!-- Select Basic --> <div class="control-group"> <label class="control-label" for="basic">Empresa</label> <div class="controls"> <select id="basic" name="basic" class="input-medium"> <option>Listos</option> <option>Tercerizar</option> <option>V&M</option> </select> </div> </div> <!-- Select Basic --> <div class="control-group"> <label class="control-label" for="Cliente">Cliente</label> <div class="controls"> <select id="Cliente" name="Cliente" class="input-medium"> <option>Harinera del Valle</option> <option>Nestle</option> <option>P&G</option> </select> </div> </div> <!-- Multiple Radios --> <div class="control-group"> <label class="control-label" for="TipoFacturacion">Tipo Facturacion</label> <div class="controls"> <label class="radio" for="TipoFacturacion-0"> <input type="radio" name="TipoFacturacion" id="TipoFacturacion-0" value="Centro de Costo" checked="checked"> Centro de Costo </label> <label class="radio" for="TipoFacturacion-1"> <input type="radio" name="TipoFacturacion" id="TipoFacturacion-1" value="N3: Ciudades"> N3: Ciudades </label> <label class="radio" for="TipoFacturacion-2"> <input type="radio" name="TipoFacturacion" id="TipoFacturacion-2" value="N4: Area"> N4: Area </label> <label class="radio" for="TipoFacturacion-3"> <input type="radio" name="TipoFacturacion" id="TipoFacturacion-3" value="N5: SubArea o CCosto Cliente"> N5: SubArea o CCosto Cliente </label> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="AIU">AIU</label> <div class="controls"> <input id="AIU" name="AIU" type="text" placeholder="%" class="input-medium"> <p class="help-block">% AIU para examenes medicos</p> </div> </div> <!-- Select Basic --> <div class="control-group"> <label class="control-label" for="ArbolCliente">Ciudad Ingreso Cliente</label> <div class="controls"> <select id="ArbolCliente" name="ArbolCliente" class="input-medium"> <option>Cali</option> <option>Bogota</option> <option>Medellin</option> <option>Palmira</option> </select> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="Niv2Cliente">ID Cliente</label> <div class="controls"> <input id="Niv2Cliente" name="Niv2Cliente" type="text" placeholder="Nivel 2 Kactus" class="input-medium"> <p class="help-block">Nivel 2 Kactus</p> </div> </div> </fieldset> </form>