<!-- Begin Body --> 
<form  role="form" id="agent_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="agent_agent"><small>Agent</small></label>
					<div class="col-md-7"><input  type="text" id="agent_agent" placeholder="Agent" value="" class="form-control text-left" name="agent_agent"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="agent_pr"><small>Agent PRC Id</small></label>
					<div class="col-md-7"><input  type="text" id="agent_pr" placeholder="Agent PRC Id" value="" class="form-control text-left" name="agent_pr"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="agent_broker"><small>Broker</small></label> 
					<div class="col-md-7"><span id="div_broker"></span></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="agent_contact"><small>Contact No.</small></label>
					<div class="col-md-7"><input type="text" name="agent_contact" id="agent_contact" placeholder="Contact No." value="" class="form-control text-left"></div>
				</div>
				<div class="form-group">
					<label class="col-md-5 control-label text-right" for="agent_email"><small>Email</small></label>
					<div class="col-md-7"><input type="text" id="agent_email" placeholder="Email" value="" class="form-control text-left" name="agent_email"></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="agent_address"><small>Address</small></label>
					<div class="col-md-7"><textarea rows="6" id="agent_address" placeholder="Address" class="form-control text-left" name="agent_address"></textarea></div>
				</div>
			</fieldset>
		</div>
	</div>
	<div class="row"><br/></div>
</div>
</form>