<!-- Begin Body --> 
<form  role="form" id="broker_form" class="form-horizontal">
<div class="container-fluid" style="padding-top:120px; height:auto">
	<div class="row"><br/></div> 
	<div class="row">
		<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12"> 
			<fieldset> 
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_broker"><small>Broker</small></label>
					<div class="col-md-7"><input  type="text" id="broker_broker" placeholder="Broker" value="" class="form-control text-left" name="broker_broker"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_contact_person"><small>Broker / Owner</small></label>
					<div class="col-md-7"><input  type="text" id="broker_contact_person" placeholder="Broker / Owner" value="" class="form-control text-left" name="broker_contact_person"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_prc_no"><small>Broker's PRC Id No.</small></label>
					<div class="col-md-7"><input  type="text" id="broker_prc_no" placeholder="Broker's PRC Id No." value="" class="form-control text-left" name="broker_prc_no"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_date_accredited"><small>Date Accredited</small></label>
					<div class="col-md-7"><input  type="text" id="broker_date_accredited" placeholder="MM/DD/YYYY" value="" class="form-control text-left datepicker" name="broker_date_accredited"></div>
				</div>
			</fieldset>
		</div>
		<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
			<fieldset>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_contact"><small>Cellphone No.</small></label>
					<div class="col-md-7"><input type="text" name="broker_contact" id="broker_contact" placeholder="Cellphone No." value="" class="form-control text-left"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_landline"><small>Landline No.</small></label>
					<div class="col-md-7"><input type="text" name="broker_landline" id="broker_landline" placeholder="Landline No." value="" class="form-control text-left"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_coordinator"><small>Coordinator</small></label>
					<div class="col-md-7"><input type="text" name="broker_coordinator" id="broker_coordinator" placeholder="Coordinator" value="" class="form-control text-left"></div>
				</div>
			</fieldset>
		</div>
		<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
			<fieldset>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_email"><small>Email</small></label>
					<div class="col-md-7"><input type="text" id="broker_email" placeholder="Email" value="" class="form-control text-left" name="broker_email"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="broker_address"><small>Address</small></label>
					<div class="col-md-7"><textarea rows="5" name="broker_address" id="broker_address" placeholder="Address" value="" class="form-control text-left"></textarea></div>
				</div>
			</fieldset>
		</div>
	</div>
	<div class="row"><br/></div>
</div>
</form>