<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>
<div class="container">
<div class="row">
<div class="col-md-6">
<img class="img-responsive img-brand" src="#"></img>
</div>
<div class="col-md-6 text-center">
<h2 class="teko-400">SAMPLE REQUEST</h2>
<h3 class="teko-300">DATE: <u>99 / 99 / 2016</u></h3>
</div>
</div>
</div>
