<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/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="col-sm-6"> <div class="alert alert-info" role="alert"> <p>Please enter your card details below.</p> </div> <hr/> <!-- Name --> <div class="form-group"> <label class="control-label" for="username">Card Holder's Name</label> <div class="controls"> <input type="text" id="username" name="username" placeholder="" class="form-control"> </div> </div> <!-- Card Number --> <div class="form-group"> <label class="control-label" for="card_number">Card Number</label> <div class="controls"> <input type="text" id="card_number" name="card_number" placeholder="" class="form-control"> </div> </div> <hr/> <!-- Expiry--> <div class="form-group"> <label class="control-label" for="expiry_month">Card Expiry Date</label> <div class="row"> <div class="col-sm-4"> <select class="form-control" 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> <option value="11">Nov (11)</option> <option value="12">Dec (12)</option> </select> </div> <div class="col-sm-3"> <select class="form-control" name="expiry_year"> <option value="">-----</option> <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> </div> <hr/> <div class="row"> <div class="col-sm-3"> <!-- CVV --> <div class="form-group"> <label class="control-label" for="password_confirm">Card CVV</label> <input type="password" id="password_confirm" name="password_confirm" placeholder="" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-sm-3"> <!-- Submit --> <div class="form-group"> <button class="btn btn-success">Pay Now</button> </div> </div> <div class="col-sm-4"></div> <div class="col-sm-5"> <!-- Space for Logo --> </div> </div> </div> </div> </div>