<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="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> </div> <div class="control-group"> <label class="control-label">Card Expiry Date</label> <div class="controls"> <div class="row-fluid"> <div class="span9"> <select class="input-block-level"> <option>January</option> <option>...</option> <option>December</option> </select> </div> <div class="span3"> <select class="input-block-level"> <option>2013</option> <option>...</option> <option>2015</option> </select> </div> </div> </div> </div> <div class="control-group"> <label class="control-label">Card CVV</label> <div class="controls"> <div class="row-fluid"> <div class="span3"> <input type="text" class="input-block-level" autocomplete="off" maxlength="3" pattern="\d{3}" title="Three digits at back of your card" required> </div> <div class="span8"> <!-- screenshot may be here --> </div> </div> </div> </div> <div class="form-actions"> <button type="submit" class="btn btn-primary">Submit</button> <button type="button" class="btn">Cancel</button> </div> </fieldset> </form> </div> </div> </div>