Credit Card Payment Form #2
<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>
,The author is msurguy





