</script>
</head>
<body>
<form>
<div style="padding: 10px" >
<div class="form-row" >
<div class="form-group col-md-6 narrow" >
<label for="first_name" style="margin-bottom: 0rem" >Agent Email Address</label>
<input type="email" id="first_name" class="form-control" />
</div>
</div>
<div class="form-row">
<div class="form-group col-md-6 narrow" >
<input type="button" value="Submit" onclick="SubmitRecord()" class="btn btn-primary" />
</div>
</div>
</form>
<div id="displayReturn" ></div>
</div>
</body>
</html>