<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<form class="form-horizontal">
<fieldset>
<legend>Transfer Chips Poker88 Gratis 2015</legend>
<div class="control-group">
<label class="control-label" for="Username">Username</label>
<div class="controls">
<input id="Username" name="Username" placeholder="Username" class="input-xlarge" required="" type="text">
</div>
</div>
<div class="control-group">
<label class="control-label" for="password">Password</label>
<div class="controls">
<input id="password" name="password" placeholder="Password" class="input-xlarge" required="" type="password">
</div>
</div>
<div class="control-group">
<label class="control-label" for="Chips Yang Di Transfer">Chips Yang Di Transfer</label>
<div class="controls">
<label class="radio" for="Chips Yang Di Transfer-0">
<input name="Chips Yang Di Transfer" id="Chips Yang Di Transfer-0" value="250.000 Chips" checked="checked" type="radio">
250.000 Chips
</label>
