"Membresía"
Bootstrap 2.3.2 Snippet by alviore

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<link href="//netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/css/bootstrap-combined.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<!------ Include the above in your HEAD tag ---------->
<div class="container">
<div class="row">
<h2>Create your snippet's HTML, CSS and Javascript in the editor tabs</h2>
<form class="form-horizontal">
<fieldset>
<!-- Form Name -->
<legend>Formato de Captura de Certificado de Membresía</legend>
<!-- Select Basic -->
<div class="control-group">
<label class="control-label" for="campo_1">Inicio de Vigencia</label>
<div class="controls">
<select id="campo_1" name="campo_1" class="input-small">
<option>Día</option>
<option>1</option>
<option>...</option>
<option>31</option>
</select>
</div>
</div>
<!-- Text input-->
<div class="control-group">
<label class="control-label" for="campo_4">Invitado por</label>
<div class="controls">
<input id="campo_4" name="campo_4" type="text" placeholder="Nombre de la persona que lo recomendó" class="input-xlarge">
</div>
</div>
<!-- Text input-->
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