"SAMPLE REQUEST FORM"
Bootstrap 3.3.0 Snippet by PPIadmin

<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> <!------ Include the above in your HEAD tag ----------> <div class="container"> <div class="row"> <div class="col-md-6"> <img class="img-responsive img-brand" src="#"></img> </div> <div class="col-md-6 text-center"> <h2 class="teko-400">SAMPLE REQUEST</h2> <h3 class="teko-300">DATE: <u>99 / 99 / 2016</u></h3> </div> </div> </div>

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