<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> <!------ Include the above in your HEAD tag ----------> <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> <!-- Name --> <div class="control-group"> <label class="control-label" for="username">CARD HOLDER'S NAME</label> <div class="controls"> <input type="text" class="form-control" id="cardNumber" placeholder="" required /> </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"> <input type="text" class="form-control" id="expityMonth" placeholder="MM" required /> </div> <div class="col-xs-6 col-lg-6 pl-ziro"> <input type="text" class="form-control" id="expityYear" placeholder="YY" required /></div> </div> </div> <div class="col-xs-5 col-md-5 pull-right"> <div class="form-group"> <label for="cvCode"> CVV2 CODE</label> <input type="password" class="form-control" id="cvCode" placeholder="CVV2" required /> </div> </div> </div> </form> </div> </div> <ul class="nav nav-pills nav-stacked"> <li class="active"><a href="#"><span class="badge pull-right"><span class="glyphicon glyphicon-usd"></span>4200</span> Invoice Total</a> </li> </ul> <br/> <a href="#" class="btn btn-success btn-lg btn-block" role="button">Pay</a> </div> </div> </div>

body { margin-top:20px; } .panel-title {display: inline;font-weight: bold;} .checkbox.pull-right { margin: 0; } .pl-ziro { padding-left: 0px; }