<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"> <form class="form-horizontal" role="form"> <fieldset> <legend>Payment</legend> <div class="form-group"> <label class="col-sm-3 control-label" for="card-holder-name">Name on Card</label> <div class="col-sm-9"> <input type="text" class="form-control" name="card-holder-name" id="card-holder-name" placeholder="Card Holder's Name"> </div> </div> <div class="form-group"> <label class="col-sm-3 control-label" for="card-number">Card Number</label> <div class="col-sm-9"> <input type="text" class="form-control" name="card-number" id="card-number" placeholder="Debit/Credit Card Number"> </div> </div> <div class="form-group"> <label class="col-sm-3 control-label" for="expiry-month">Expiration Date</label> <div class="col-sm-9"> <div class="row"> <div class="col-xs-3"> <select class="form-control col-sm-2" name="expiry-month" id="expiry-month"> <option>Month</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-xs-3"> <select class="form-control" 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> </div> </div> <div class="form-group"> <label class="col-sm-3 control-label" for="cvv">Card CVV</label> <div class="col-sm-3"> <input type="text" class="form-control" name="cvv" id="cvv" placeholder="Security Code"> </div> </div> <div class="form-group"> <div class="col-sm-offset-3 col-sm-9"> <button type="button" class="btn btn-success">Pay Now</button> </div> </div> </fieldset> </form> </div>