<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 ----------> <div class="container"> <div class="row"> <h2>Create your snippet's HTML, CSS and Javascript in the editor tabs</h2> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Formato de Captura de Certificado de Membresía</legend> <!-- Select Basic --> <div class="control-group"> <label class="control-label" for="campo_1">Inicio de Vigencia</label> <div class="controls"> <select id="campo_1" name="campo_1" class="input-small"> <option>Día</option> <option>1</option> <option>...</option> <option>31</option> </select> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_4">Invitado por</label> <div class="controls"> <input id="campo_4" name="campo_4" type="text" placeholder="Nombre de la persona que lo recomendó" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_5">Número SIP</label> <div class="controls"> <input id="campo_5" name="campo_5" type="text" placeholder="" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_6">Folio relacionado</label> <div class="controls"> <input id="campo_6" name="campo_6" type="text" placeholder="Folio que aparece en la póliza" class="input-large"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_7">Titular</label> <div class="controls"> <input id="campo_7" name="campo_7" type="text" placeholder="Nombre" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_8"></label> <div class="controls"> <input id="campo_8" name="campo_8" type="text" placeholder="Apellido Paterno" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_9"></label> <div class="controls"> <input id="campo_9" name="campo_9" type="text" placeholder="Apellido Materno" class="input-xlarge"> </div> </div> <!-- Select Basic --> <div class="control-group"> <label class="control-label" for="campo_10">Fecha de Nacimiento</label> <div class="controls"> <select id="campo_10" name="campo_10" class="input-small"> <option>Día</option> <option>1</option> <option>...</option> <option>31</option> </select> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_13">R.F.C.</label> <div class="controls"> <input id="campo_13" name="campo_13" type="text" placeholder="" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_14">C.U.R.P.</label> <div class="controls"> <input id="campo_14" name="campo_14" type="text" placeholder="" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_15">Correo Electrónico</label> <div class="controls"> <input id="campo_15" name="campo_15" type="text" placeholder="" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_15a">Confirmar Correo</label> <div class="controls"> <input id="campo_15a" name="campo_15a" type="text" placeholder="" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_16">Correo Alterno</label> <div class="controls"> <input id="campo_16" name="campo_16" type="text" placeholder="" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_17">Redes Sociales</label> <div class="controls"> <input id="campo_17" name="campo_17" type="text" placeholder="Facebook" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_18"></label> <div class="controls"> <input id="campo_18" name="campo_18" type="text" placeholder="Twitter" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_19"></label> <div class="controls"> <input id="campo_19" name="campo_19" type="text" placeholder="Linkedin" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_20"></label> <div class="controls"> <input id="campo_20" name="campo_20" type="text" placeholder="Skype" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_21"></label> <div class="controls"> <input id="campo_21" name="campo_21" type="text" placeholder="Otro" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_22">Teléfonos</label> <div class="controls"> <input id="campo_22" name="campo_22" type="text" placeholder="Casa" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_23"></label> <div class="controls"> <input id="campo_23" name="campo_23" type="text" placeholder="Oficina" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_24"></label> <div class="controls"> <input id="campo_24" name="campo_24" type="text" placeholder="Movil" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_25">Dirección</label> <div class="controls"> <input id="campo_25" name="campo_25" type="text" placeholder="Calle / Avenida" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_26"></label> <div class="controls"> <input id="campo_26" name="campo_26" type="text" placeholder="Número Exterior" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_27"></label> <div class="controls"> <input id="campo_27" name="campo_27" type="text" placeholder="Número Interior" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_28"></label> <div class="controls"> <input id="campo_28" name="campo_28" type="text" placeholder="Colonia" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_29"></label> <div class="controls"> <input id="campo_29" name="campo_29" type="text" placeholder="Delegación / Municipio" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_30"></label> <div class="controls"> <input id="campo_30" name="campo_30" type="text" placeholder="Ciudad" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_31"></label> <div class="controls"> <input id="campo_31" name="campo_31" type="text" placeholder="Estado" class="input-xlarge"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_32"></label> <div class="controls"> <input id="campo_32" name="campo_32" type="text" placeholder="Código Postal" class="input-medium"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_33">Banco</label> <div class="controls"> <input id="campo_33" name="campo_33" type="text" placeholder="" class="input-large"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_34">Tipo de Cuenta</label> <div class="controls"> <input id="campo_34" name="campo_34" type="text" placeholder="" class="input-large"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_35">Número de Cuenta</label> <div class="controls"> <input id="campo_35" name="campo_35" type="text" placeholder="" class="input-large"> </div> </div> <!-- Text input--> <div class="control-group"> <label class="control-label" for="campo_36">CLABE</label> <div class="controls"> <input id="campo_36" name="campo_36" type="text" placeholder="" class="input-xlarge"> </div> </div> <!-- Button --> <div class="control-group"> <label class="control-label" for="save"></label> <div class="controls"> <button id="save" name="save" class="btn btn-success">Guardar y continuar</button> </div> </div> </fieldset> </form> </div> </div>