Bootstrap Snippet payment receipt using HTML CSS Bootstrap

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<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>
<!------ Include the above in your HEAD tag ---------->
<div class="container">
<div class="reciept">
    <div class="row" style="margin-top:10px;">
        <div class="col-md-8">
            <div class="col-md-3">
            <img class="media-object img-thumbnail user-img" style="height: 80px;" alt="User Picture" src="http://via.placeholder.com/80x80"></div>
           <div class="col-md-9 text-right">
            <h4 class="heading">Aspirant English Classess</h4>
            <h5 class="heading">Hanuman Mandir C.C.Road, Deoria</h5>
            <h6 class="heading">+91 9455078760</h6>
            </div>
        </div>
        <div class="col-md-4">
            
            <div class="form-group">
              <label class="col-md-4 control" >Date :</label>
              <div class="col-md-8">
                <input id="" name="name" type="text" placeholder="10-May-2017 02:05 pm" class="form-control">
              </div>
            </div>
                        
            <div class="form-group">
              <label class="col-md-4 control" >Reciept No. :</label>
              <div class="col-md-8">
                <input id="" name="name" type="text" placeholder="12349" class="form-control">
              </div>
            </div>
                        
        </div>
    </div>
    <br/>
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input[type="text"]{
        border-top: none !important;
        border-right: none !important;
        border-left: none !important;
        border-bottom: 1px dotted #2196f3 !important;
        box-shadow: none !important;
        -webkit-box-shadow: none !important;
        -moz-box-shadow: none !important;
        -moz-transition: none !important;
        -webkit-transition: none !important;
    }
    
    .heading{
    color: #2196f3;
}
.control{
padding-top:7px;
}
.reciept{
    border-top: 5px solid #2196f3;
    -webkit-box-shadow: 0px 5px 21px -2px rgba(0,0,0,0.47);
    -moz-box-shadow: 0px 5px 21px -2px rgba(0,0,0,0.47);
    box-shadow: 0px 5px 21px -2px rgba(0,0,0,0.47);
    margin-top: 10px;
    margin-bottom: 10px;
}
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"payment receipt"
Bootstrap 3.3.0 Snippet by Anjani Barnwal

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"payment receipt" Bootstrap 3.3.0 Snippet by Anjani Barnwal

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"payment receipt"
Bootstrap 3.3.0 Snippet by Anjani Barnwal