<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> <!------ Include the above in your HEAD tag ----------> <div class="container"> <div class="col-sm-6"> <fieldset> <legend>Payment</legend> <div class="form-group"> <label label-default="" class="control-label">Card Holder's Name</label> <div class="controls"> <input type="text" class="form-control" pattern="\w+ \w+.*" title="First and last name" required=""> </div> </div> <div class="form-group"> <label label-default="" class="control-label">Card Number</label> <div class="controls"> <div class="row"> <div class="col-md-3"> <input type="text" class="form-control" autocomplete="off" maxlength="4" pattern="\d{4}" title="First four digits" required=""> </div> <div class="col-md-3"> <input type="text" class="form-control" autocomplete="off" maxlength="4" pattern="\d{4}" title="Second four digits" required=""> </div> <div class="col-md-3"> <input type="text" class="form-control" autocomplete="off" maxlength="4" pattern="\d{4}" title="Third four digits" required=""> </div> <div class="col-md-3"> <input type="text" class="form-control" autocomplete="off" maxlength="4" pattern="\d{4}" title="Fourth four digits" required=""> </div> </div> </div> </div> <div class="form-group"> <label label-default="" class="control-label">Card Expiry Date</label> <div class="controls"> <div class="row"> <div class="col-md-9"> <select class="form-control" name="cc_exp_mo"> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11">November</option> <option value="12">December</option> </select> </div> <div class="col-md-3"> <select class="form-control" name="cc_exp_yr"> <option>2014</option> <option>2015</option> <option>2016</option> <option>2017</option> <option>2018</option> <option>2019</option> <option>2020</option> <option>2021</option> <option>2022</option> </select> </div> </div> </div> </div> <div class="form-group"> <label label-default="" class="control-label">Card CVV</label> <div class="controls"> <div class="row"> <div class="col-md-3"> <input type="text" class="form-control" autocomplete="off" maxlength="3" pattern="\d{3}" title="Three digits at back of your card" required=""> </div> <div class="col-md-8"></div> </div> </div> </div> <div class="form-group"> <label label-default="" class="control-label"></label> <div class="controls"> <button type="submit" class="btn btn-primary">Submit</button> <button type="button" class="btn btn-default">Cancel</button> </div> </div> </fieldset> </div> </div> <hr>