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<title>Registro para Manual de Aguas Residuales</title>
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<b><center><legend>Registro para Manual de Aguas Residuales</legend></center></b>

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<div class="form-group">
<label class="col-md-4 control-label">Nombre</label>
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<input name="first_name" placeholder="Nombre Completo" class="form-control" type="text">
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<label class="col-md-4 control-label" >Apellidos</label>
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<input name="last_name" placeholder="Apellido Completo" class="form-control" type="text">
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<input name="email" placeholder="Correo @ Electronico" class="form-control" type="text">
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<input name="phone" placeholder="Fijo o Celular" class="form-control" type="text">
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<input name="address" placeholder="Empresa donde Trabaja" class="form-control" type="text">
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<label class="col-md-4 control-label">Segmento Laboral</label>
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<select name="state" class="form-control selectpicker" >
<option value=" " >Selecciona Segmento Laboral</option>
<option>Automotores</option>
<option>Salud</option>
<option >Restaurantes</option>
<option >Hoteles</option>
<option>Industriales</option>
<option >Otros</option>
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<button type="submit" class="btn btn-warning" onclick="cerrar()">Registrarse<span class="glyphicon glyphicon-send"></span></button>
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function cerrar() {
setTimeout(function(){
$("body").html('<div alignt="center"><h1>Enviado Exitosamente!!!</h1></div>'); //Marca nuevo contenido con un mensaje que se envio exitosamente
},3000); //Dejara un tiempo de 3 seg para que el usuario vea que se envio el formulario correctamente
window.close();
}
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<!-- Success message -->
<div class="alert alert-success" role="alert" id="success_message">Registro Exitoso <i class="glyphicon glyphicon-thumbs-up"></i> Gracias por registrarse para recibir el manual de aguas residuales, verificaremos sus datos y en breve le haremos envio</div>
</fieldset>
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