<link href="//netdna.bootstrapcdn.com/bootstrap/3.2.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/bootstrap/3.2.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<form class="form-horizontal">
<fieldset>
<legend>Surat Pernyataan</legend>
<div class="form-group">
<label class="col-md-4 control-label" for="nama">Nama</label>
<div class="col-md-4">
<input id="nama" name="nama" type="text" placeholder="nama" class="form-control input-md">
</div>
</div>
<div class="form-group">
<label class="col-md-4 control-label" for="nip">NIP</label>
<div class="col-md-4">
<input id="nip" name="nip" type="text" placeholder="NIP" class="form-control input-md">
</div>
</div>
<div class="form-group">
<label class="col-md-4 control-label" for="pangkat">Pangkat/Gol</label>
<div class="col-md-4">
<input id="pangkat" name="pangkat" type="text" placeholder="Pangkat/Gol" class="form-control input-md">
</div>
</div>