<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/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-xs-12 col-md-4">
<div class="panel panel-default">
<div class="panel-heading">
<h3 class="panel-title">
Payment Details
</h3>
<div class="checkbox pull-right">
<label>
<input type="checkbox" />
Remember
</label>
</div>
</div>
<div class="panel-body">
<form role="form">
<div class="form-group">
<label for="cardNumber">
CARD NUMBER</label>
<div class="input-group">
<input type="text" class="form-control" id="cardNumber" placeholder="Valid Card Number"
required autofocus />
<span class="input-group-addon"><span class="glyphicon glyphicon-lock"></span></span>
</div>
</div>
<div class="row">
<div class="col-xs-7 col-md-7">
<div class="form-group">
<label for="expityMonth">
EXPIRY DATE</label>
<div class="col-xs-6 col-lg-6 pl-ziro">