<!-- Begin Body --> 
<form  role="form" id="brokeragent_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="code"><small>Code</small></label>
					<div class="col-md-7"><input  type="text" id="code" placeholder="Code" value="" class="form-control text-left" name="code"></div>
				</div>

				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="fullname"><small>Fullname</small></label>
					<div class="col-md-7"><input  type="text" id="fullname" placeholder="Fullname" value="" class="form-control text-left" name="fullname"></div>
				</div>

				  
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="brokeragent"><small>Broker / Agent</small></label>
					<div class="col-md-7">
						<select class="form-control" name="brokeragent" id="brokeragent">
							<option value="">- Select Type -</option>
							<option value="agent">Agent</option>
							<option value="broker">Broker</option>
						</select>
					</div>
				</div>	
				 
			</fieldset>
		</div>
		<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
			<fieldset>  
				<div class="form-group">
					<input id="brokername" type="hidden" readonly>
					<label class="col-md-5 control-label text-right" for="realty"><small><a href="index.php?pg=settings&type=broker" target="_blank">Realty</a></small>&nbsp;&nbsp;<p onclick="reloadBroker();" class="btn btn-xs btn-info refresh"><span class="glyphicon glyphicon-refresh"></span></p></label> 
					<div class="col-md-7"><!--<span id="div_broker"></span>-->
						<span id="div_brokeragent"></span>  
					</div>
				</div>


				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="dateapplicationreceived"><small>Date Application Received</small></label>
					<div class="col-md-7"><input type="text" name="dateapplicationreceived" id="dateapplicationreceived" placeholder="MM/DD/YYYY" value="" class="form-control datepicker text-right"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="dateappliedatmetrobank"><small>Date Applied at Metrobank Annapolis</small></label>
					<div class="col-md-7">  
						<input type="text" class="datepicker form-control text-right" name="dateappliedatmetrobank" id="dateappliedatmetrobank" placeholder="MM/DD/YYYY">
					</div>
				</div> 
			</fieldset>
		</div>
		<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
			<fieldset>
				<div class="form-group left">
					<label class="col-md-5 control-label left text-left" for="cashcardnumber"><small>Cash Card Number</small></label>
					<div class="col-md-7"><input type="text" id="cashcardnumber" placeholder="Cash Card Number" value="" class="form-control text-left" name="cashcardnumber" onkeypress="return isNumberKey(event)"></div>
				</div>
				<div class="form-group left">
					<label class="col-md-5 control-label left text-left" for="accountnumber"><small>Account Number</small></label>
					<div class="col-md-7"><input type="text" id="accountnumber" placeholder="Account Number" value="" class="form-control text-left" name="accountnumber" onkeypress="return isNumberKey(event)"></div>
				</div>
				<div class="form-group left">
					<label class="col-md-5 control-label left text-left" for="remarks"><small>Remarks</small></label>
					<div class="col-md-7"><input type="text" id="remarks" placeholder="Remarks" value="" class="form-control text-left" name="remarks"></div>
				</div>
			</fieldset>
		</div>
	</div>
	<div class="row"><br/></div>
</div>
</form>