<link href="//netdna.bootstrapcdn.com/bootstrap/3.2.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/bootstrap/3.2.0/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="col-md-12"><h4 class="modal-title my-modal-label">Please enter your payment information below</h4></div>
<div class='col-md-4 col-xs-2'></div>
<div class='col-md-4 col-xs-8'>
<script src='https://js.stripe.com/v2/' type='text/javascript'></script>
<form accept-charset="UTF-8" action="/" class="require-validation" data-cc-on-file="false" data-stripe-publishable-key="pk_bQQaTxnaZlzv4FnnuZ28LFHccVSaj" id="payment-form" method="post"><div style="margin:0;padding:0;display:inline"><input name="utf8" type="hidden" value="✓" /><input name="_method" type="hidden" value="PUT" /><input name="authenticity_token" type="hidden" value="qLZ9cScer7ZxqulsUWazw4x3cSEzv899SP/7ThPCOV8=" /></div>
<div class='form-row'>
<div class='col-xs-12 form-group required'>
<label class='control-label'>Name on Card</label>
<input class='form-control' size='4' type='text'>
</div>
</div>
<div class='form-row'>
<div class='col-xs-12 form-group card required'>
<label class='control-label'>Card Number</label>
<input autocomplete='off' class='form-control card-number' size='20' type='text'>
</div>
</div>
<div class='form-row'>
<div class='col-xs-4 form-group cvc required'>
<label class='control-label'>CVC</label>
<input autocomplete='off' class='form-control card-cvc' placeholder='ex. 311' size='4' type='text'>
</div>