<form role="form" class="form-horizontal">
<div class="col-xs-12 well" style="border: 1px solid black;">
<div class="col-xs-6" style="margin-top: 1em;" >
<div class="form-group">
<label class="control-label col-xs-4" for="requestor_name">Requestor Name:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="requestor_name"/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="requestor_phone">Requestor Phone:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="requestor_phone"/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="requestor_email">Requestor email:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="requestor_email"/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="site_address">Site Address:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="site_address"/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="csz">City, State, ZIP:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="csz"/>
</div>
</div>
</div> <!-- /.div col-xs-6 (form left column)-->
<div class="col-xs-6" style="margin-top: 1em;" >
<div class="form-group">
<label class="control-label col-xs-4" for="date_requested">Date Requested:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="date_requested"'/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="site_contact_name">Site Contact Name:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="site_contact_name"'/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="site_contact_phone">Site Contact Phone:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="site_contact_phone"'/>
</div>
</div>
<div class="form-group">
<label class="control-label col-xs-4" for="site_contact_email">Site Contact Email:</label>
<div class="col-xs-8">
<input class="form-control" type="text" name="site_contact_email"'>
</div>
</div>
</div> <!-- /.div col-xs-6 (form right column)-->
</div><!-- End of contact information div -->
<div class="col-xs-12"><h3>Request Details</h3></div>
<div class="col-xs-12 well" style="border: 1px solid black;">
<div class="col-xs-6 form-group">
<label class="control-label col-xs-4" for="service_type">Type of Service Requested:</label>
<div class="col-xs-8">
<table>
<tr>
<td>
<input type="radio" name="service_type" value="access_control">Access Control
</td>
<td>
<input type="radio" name="service_type" value="intrusion">Intrusion
</td>
</tr>
<tr>
<td>
<input type="radio" name="service_type" value="video">Video
</td>
<td>
<input type="radio" name="service_type" value="other">Other
</td>
</tr>
</table>
</div>
</div> <!-- /.div col-xs-6 (form left column)-->
<div class="col-xs-6 form-group">
<label class="control-label col-xs-4" for="service_type">Priority Level:</label>
<div class="col-xs-8">
<table>
<tr>
<td>
<input type="radio" name="priority_level" value="standard_response">Standard Response
</td>
</tr>
<tr>
<td>
<input type="radio" name="priority_level" value="urgent_response">Urgent Response
</td>
</tr>
</table>
</div>
</div> <!-- /.div col-xs-6 (form left column)-->
<div class="col-xs-12 form-group">
<label class="control_label col-xs-4" for="detailed_description">Detailed Incident Description:</label>
<div class="col-xs-8">
<textarea style="width: 100%;" name="detailed_description"></textarea>
</div>
</div>
<div class="col-xs-12 form-group">
<label class="control_label col-xs-4" for="site_specific">Site Specific Requirements and/or Restrictions:</label>
<div class="col-xs-8">
<textarea style="width: 100%;" name="site_specific"></textarea>
</div>
</div>
<div class="col-xs-12 form-group">
<label class="control_label col-xs-4" for="after_hours">After Hours Service Requested:</label>
<div class="col-xs-8">
<table><tr><td>
<input type="radio" name="after_hours" value="yes">Yes
</td><td>
<input type="radio" name="after_hours" value="no">No
</td></tr>
<tr><td colspan="2">
<p><strong>
*Please Note: After hours rates and 4 hour minimum will apply unless otherwise
covered by a Platinum Maintenance Agreement. Business hours are 8:00 a.m.-5:00 p.m.
M-F, excluding holidays. Anything outside of this time frame is considered after hours
</strong></p>
</td></tr>
</table>
</div>
</div>
</div> <!-- End of request details div -->
</form>