<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-fluid">
<form class="form-horizontal">
<fieldset>
<div id="legend">
<legend class="">Payment</legend>
</div>
<div class="control-group">
<label class="control-label" for="username">Card Holder's Name</label>
<div class="controls">
<input type="text" id="username" name="username" placeholder="" class="input-xlarge">
</div>
</div>
<div class="control-group">
<label class="control-label" for="email">Card Number</label>
<div class="controls">
<input type="text" id="email" name="email" placeholder="" class="input-xlarge">
</div>
</div>
<div class="control-group">
<label class="control-label" for="password">Card Expiry Date</label>
<div class="controls">
<select class="span3" name="expiry_month" id="expiry_month">
<option></option>
<option value="01">Jan (01)</option>
<option value="02">Feb (02)</option>
