<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-fluid"> <form class="form-horizontal"> <fieldset> <div id="legend"> <legend class="">Payment</legend> </div> <!-- Name --> <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> <!-- Card Number --> <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> <!-- Expiry--> <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> <option value="03">Mar (03)</option> <option value="04">Apr (04)</option> <option value="05">May (05)</option> <option value="06">June (06)</option> <option value="07">July (07)</option> <option value="08">Aug (08)</option> <option value="09">Sep (09)</option> <option value="10">Oct (10)</option>1 <option value="11">Nov (11)</option> <option value="12">Dec (12)</option> </select> <select class="span2" name="expiry_year"> <option value="13">2013</option> <option value="14">2014</option> <option value="15">2015</option> <option value="16">2016</option> <option value="17">2017</option> <option value="18">2018</option> <option value="19">2019</option> <option value="20">2020</option> <option value="21">2021</option> <option value="22">2022</option> <option value="23">2023</option> </select> </div> </div> <!-- CVV --> <div class="control-group"> <label class="control-label" for="password_confirm">Card CVV</label> <div class="controls"> <input type="password" id="password_confirm" name="password_confirm" placeholder="" class="span2"> </div> </div> <!-- Save card --> <div class="control-group"> <div class="controls"> <label class="checkbox" for="save_card"> <input type="checkbox" id="save_card" value="option1"> Save card on file? </label> </div> </div> <!-- Submit --> <div class="control-group"> <div class="controls"> <button class="btn btn-success">Pay Now</button> </div> </div> </fieldset> </form> </div> </div>