<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>
<div class="container">
<div class="row" style="margin-top:20px">
<div class="col-xs-12 col-sm-8 col-md-6 col-sm-offset-2 col-md-offset-3">
<form role="form">
<fieldset>
<div class="row">
<div class="col-xs-2 col-sm-2 col-md-2">
<img src="http://i67.tinypic.com/d9mx5.png" width="60px">
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<h2>PLN</h2>
<span>Prabayar</span>
</div>
</div>
<div class="form-group">
<input type="text" name="phone" id="email" class="form-control input-lg" placeholder="Masukkan nomor meter">
</div>
<div class="form-group">
<select name="nominal" id="password" class="form-control input-lg">
<option>Pilih nominal pulsa</option>
<option>Rp 22.000,-</option>
<option>Rp 52.000,-</option>
<option>Rp 102.000,-</option>
<option>Rp 202.000,-</option>
<option>Rp 502.000,-</option>
</select>
</div>
<div class="row">
<input type="submit" class="btn btn-lg btn-success btn-block" value="PROSES">
</div>
</fieldset>
</form>
