<link href="//netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/css/bootstrap-combined.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<div class="container">
<div class="row">
<div class="span12">
<form class="form-horizontal span6">
<fieldset>
<legend>Payment</legend>
<div class="control-group">
<label class="control-label">Card Holder's Name</label>
<div class="controls">
<input type="text" class="input-block-level" pattern="\w+ \w+.*" title="Fill your first and last name" required>
</div>
</div>
<div class="control-group">
<label class="control-label">Card Number</label>
<div class="controls">
<div class="row-fluid">
<div class="span3">
<input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="First four digits" required>
</div>
<div class="span3">
<input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="Second four digits" required>
</div>
<div class="span3">
<input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="Third four digits" required>
</div>
<div class="span3">
<input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="Fourth four digits" required>
</div>
</div>
</div>
