Помощь по форме

<style>.btn-label {position: relative;left: -12px;display: inline-block;padding: 6px 12px;background: rgba(0,0,0,0.15);border-radius: 3px 0 0 3px;}
.btn-labeled {padding-top: 0;padding-bottom: 0;}
.input-group { margin-bottom:10px; }
.separator { border-right: 1px solid #dfdfe0; }
.facebook,.twitter { min-width:170px; }
.facebook { background-color:#354E84;color:#fff; }
.twitter { background-color:#00A5E3;color:#fff; }
.facebook:hover,.twitter:hover { color:#fff; }</style>
<div class="row">
        <div class="col-md-9">
            <div class="panel panel-success">
                <div class="panel-heading">Регистрация</div>
                <div class="panel-body">
                    <div class="panel-body">                    
<div class="row">
     <div class="col-xs-6 col-sm-6 col-md-6 separator login-box"> <br />
     <form action="/index.php?verify=create" role="form">
<div class="input-group">
<span class="input-group-addon"><span class="glyphicon glyphicon-user"></span></span>
<input type="text" class="form-control" placeholder="Введите логин" required autofocus />
</div>
<div class="input-group">
<span class="input-group-addon"><span class="glyphicon glyphicon-envelope"></span></span>
<input type="text" class="form-control" placeholder="Введите email" required autofocus />
</div>
<div class="input-group">
  <span class="input-group-addon"><span class="glyphicon glyphicon-list-alt"></span></span>
<input type="text" class="form-control" placeholder="Введите имя" required autofocus />
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6 login-box">
<div class="input-group">
<span class="input-group-addon"><span class="glyphicon glyphicon-lock"></span></span>
<input type="password" class="form-control" placeholder="Ведите пароль" required autofocus />
</div>
<div class="input-group">
<span class="input-group-addon"><span class="glyphicon glyphicon-lock"></span></span>
<input type="password" class="form-control" placeholder="Повторите пароль" required />
</div>
  <div class="input-group">
<span class="input-group-addon"><span class="glyphicon glyphicon-gift"></span></span>
<input type="text" class="form-control" placeholder="Gift Code" required />
</div>
</div>
</div>
<div class="panel-footer">
<div class="row">
     <div class="col-xs-6 col-sm-6 col-md-6">
<div class="checkbox">
<label>
<input type="checkbox" value="Remember">
Я согласен с <a href="/index.php?page=dogovor">условиями и правилами</a> сайта.
</label>
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<center><button type="submit" class="btn btn-labeled btn-success">
<span class="btn-label"><i class="glyphicon glyphicon-ok"></i></span>Зарегестрироваться</button></center> </form>
</div>
</div>
  </div>
</div>
</div>
</div>
</div>