<div id="msw_fm_area">
  <form method="post" action="#">
    <div class="row">
      <div class="col-lg-9 col-md-8">

        <div class="panel panel-default">
          <div class="panel-body">
            {$TEXT[3]}
          </div>
        </div>

        <div class="panel panel-default">
          <div class="panel-body">
            <div class="form-group">
              <label>{$TEXT[0]}</label>
              <div class="form-group input-group">
                <span class="input-group-addon"><i class="fa fa-user-o fa-fw"></i></span>
                <input type="text" class="form-control" name="fm[fn]" value="">
              </div>
            </div>
            <div class="form-group">
              <label>{$TEXT[1]}</label>
              <div class="form-group input-group">
                <span class="input-group-addon"><i class="fa fa-user-o fa-fw"></i></span>
                <input type="text" class="form-control" name="fm[ln]" value="">
              </div>
            </div>
            <div class="form-group">
              <label>{$TEXT[2]}</label>
              <div class="form-group input-group">
                <span class="input-group-addon"><i class="fa fa-envelope-o fa-fw"></i></span>
                <input type="text" class="form-control" name="fm[em]" value="">
              </div>
            </div>
            
            {* == LOAD BASIC CAPTCHA IF ENABLED - html/captcha.htm == *}

            {$CAPTCHA | noescape}
            
            {* == IS PRIVACY POLICY ENABLED? == *}
            
            {if $PP == 'yes'}
            <hr>
            <div class="form-group">
              <label>{$PTEXT[0][4]}:</label>
              <div class="checkbox">
                <label><input type="checkbox" name="fm[privacy]" value="yes"> {$PTEXT[0][3]} <a href="{$META['basehref']}?tos=yes" onclick="_aff_ibox(this);return false">{$PTEXT[0][4]}</a></label>
              </div>
            </div>
            {/if}
            
          </div>
          <div class="panel-footer text-center">
            <button class="btn btn-primary" type="button" data-processor="create"><i class="fa fa-check fa-fw"></i> {$FTEXT[4]}</button>
          </div>
        </div>

      </div>
      <div class="col-lg-3 col-md-4">
        {include 'right-panel.tpl'}
      </div>
    </div>
  </form>
</div>