<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/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" id="wrap"> <div class="row"> <div class="col-md-6 col-md-offset-3"> <form action="r" method="post" accept-charset="utf-8" class="form" role="form"> <legend>Sign Up</legend> <h4>It's free and always will be.</h4> <div class="row"> <div class="col-xs-6 col-md-6"> <input type="text" name="firstname" value="" class="form-control input-lg" placeholder="First Name" /> </div> <div class="col-xs-6 col-md-6"> <input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Last Name" /> </div> </div> <input type="text" name="email" value="" class="form-control input-lg" placeholder="Your Email" /><input type="password" name="password" value="" class="form-control input-lg" placeholder="Password" /><input type="password" name="confirm_password" value="" class="form-control input-lg" placeholder="Confirm Password" /> <label>Birth Date</label> <div class="row"> <div class="col-xs-4 col-md-4"> <select name="month" class = "form-control input-lg"> <option value="01">Jan</option> <option value="02">Feb</option> <option value="03">Mar</option> <option value="04">Apr</option> <option value="05">May</option> <option value="06">Jun</option> <option value="07">Jul</option> <option value="08">Aug</option> <option value="09">Sep</option> <option value="10">Oct</option> <option value="11">Nov</option> <option value="12">Dec</option> </select> </div> <div class="col-xs-4 col-md-4"> <select name="day" class = "form-control input-lg"> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30">30</option> <option value="31">31</option> </select> </div> <div class="col-xs-4 col-md-4"> <select name="year" class = "form-control input-lg"> <option value="1935">1935</option> <option value="1936">1936</option> <option value="1937">1937</option> <option value="1938">1938</option> <option value="1939">1939</option> <option value="1940">1940</option> <option value="1941">1941</option> <option value="1942">1942</option> <option value="1943">1943</option> <option value="1944">1944</option> <option value="1945">1945</option> <option value="1946">1946</option> <option value="1947">1947</option> <option value="1948">1948</option> <option value="1949">1949</option> <option value="1950">1950</option> <option value="1951">1951</option> <option value="1952">1952</option> <option value="1953">1953</option> <option value="1954">1954</option> <option value="1955">1955</option> <option value="1956">1956</option> <option value="1957">1957</option> <option value="1958">1958</option> <option value="1959">1959</option> <option value="1960">1960</option> <option value="1961">1961</option> <option value="1962">1962</option> <option value="1963">1963</option> <option value="1964">1964</option> <option value="1965">1965</option> <option value="1966">1966</option> <option value="1967">1967</option> <option value="1968">1968</option> <option value="1969">1969</option> <option value="1970">1970</option> <option value="1971">1971</option> <option value="1972">1972</option> <option value="1973">1973</option> <option value="1974">1974</option> <option value="1975">1975</option> <option value="1976">1976</option> <option value="1977">1977</option> <option value="1978">1978</option> <option value="1979">1979</option> <option value="1980">1980</option> <option value="1981">1981</option> <option value="1982">1982</option> <option value="1983">1983</option> <option value="1984">1984</option> <option value="1985">1985</option> <option value="1986">1986</option> <option value="1987">1987</option> <option value="1988">1988</option> <option value="1989">1989</option> <option value="1990">1990</option> <option value="1991">1991</option> <option value="1992">1992</option> <option value="1993">1993</option> <option value="1994">1994</option> <option value="1995">1995</option> <option value="1996">1996</option> <option value="1997">1997</option> <option value="1998">1998</option> <option value="1999">1999</option> <option value="2000">2000</option> <option value="2001">2001</option> <option value="2002">2002</option> <option value="2003">2003</option> <option value="2004">2004</option> <option value="2005">2005</option> <option value="2006">2006</option> <option value="2007">2007</option> <option value="2008">2008</option> <option value="2009">2009</option> <option value="2010">2010</option> <option value="2011">2011</option> <option value="2012">2012</option> <option value="2013">2013</option> </select> </div> </div> <label>Gender : </label> <label class="radio-inline"> <input type="radio" name="gender" value="M" id=male /> Male </label> <label class="radio-inline"> <input type="radio" name="gender" value="F" id=female /> Female </label> <br /> <span class="help-block">By clicking Create my account, you agree to our Terms and that you have read our Data Use Policy, including our Cookie Use.</span> <button class="btn btn-lg btn-primary btn-block signup-btn" type="submit"> Create my account</button> </form> </div> </div> </div> </div>