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Payment.html
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<!DOCTYPE html>
<html>
<head>
<title>Payment Form</title>
<link href="https://fonts.googleapis.com/css?family=Roboto:300,400,500,700" rel="stylesheet">
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.5.0/css/all.css" integrity="sha384-B4dIYHKNBt8Bc12p+WXckhzcICo0wtJAoU8YZTY5qE0Id1GSseTk6S+L3BlXeVIU" crossorigin="anonymous">
<style>
html, body {
min-height: 100%;
}
body, div, form, input, select, textarea, label, p {
padding: 0;
margin: 0;
outline: none;
font-family: Roboto, Arial, sans-serif;
font-size: 14px;
color: #666;
line-height: 22px;
}
h1 {
position: absolute;
margin: 0;
font-size: 40px;
color: #fff;
z-index: 2;
line-height: 83px;
}
textarea {
width: calc(100% - 12px);
padding: 5px;
}
.testbox {
display: flex;
justify-content: center;
align-items: center;
height: inherit;
padding: 20px;
}
form {
width: 100%;
padding: 20px;
border-radius: 6px;
background: #fff;
box-shadow: 0 0 8px #669999;
}
.banner {
position: relative;
height: 300px;
background-image: url("/uploads/media/default/0001/02/c1504011491c4e04e5158b63a27a4ea654b03ed1.jpeg");
background-size: cover;
display: flex;
justify-content: center;
align-items: center;
text-align: center;
}
.banner::after {
content: "";
background-color: rgba(0, 0, 0, 0.2);
position: absolute;
width: 100%;
height: 100%;
}
input, select, textarea {
margin-bottom: 10px;
border: 1px solid #ccc;
border-radius: 3px;
}
input {
width: calc(100% - 10px);
padding: 5px;
}
input[type="date"] {
padding: 4px 5px;
}
textarea {
width: calc(100% - 12px);
padding: 5px;
}
.item:hover p, .item:hover i, .question:hover p, .question label:hover, input:hover::placeholder {
color: #669999;
}
.item input:hover, .item select:hover, .item textarea:hover {
border: 1px solid transparent;
box-shadow: 0 0 3px 0 #669999;
color: #669999;
}
.item {
position: relative;
margin: 10px 0;
}
.item span {
color: red;
}
.week {
display:flex;
justfiy-content:space-between;
}
.colums {
display:flex;
justify-content:space-between;
flex-direction:row;
flex-wrap:wrap;
}
.colums div {
width:48%;
}
input[type="date"]::-webkit-inner-spin-button {
display: none;
}
.item i, input[type="date"]::-webkit-calendar-picker-indicator {
position: absolute;
font-size: 20px;
color: #a3c2c2;
}
.item i {
right: 1%;
top: 30px;
z-index: 1;
}
input[type=radio], input[type=checkbox] {
display: none;
}
label.radio {
position: relative;
display: inline-block;
margin: 5px 20px 15px 0;
cursor: pointer;
}
.question span {
margin-left: 30px;
}
.question-answer label {
display: block;
}
label.radio:before {
content: "";
position: absolute;
left: 0;
width: 17px;
height: 17px;
border-radius: 50%;
border: 2px solid #ccc;
}
input[type=radio]:checked + label:before, label.radio:hover:before {
border: 2px solid #669999;
}
label.radio:after {
content: "";
position: absolute;
top: 6px;
left: 5px;
width: 8px;
height: 4px;
border: 3px solid #669999;
border-top: none;
border-right: none;
transform: rotate(-45deg);
opacity: 0;
}
input[type=radio]:checked + label:after {
opacity: 1;
}
.flax {
display:flex;
justify-content:space-around;
}
.btn-block {
margin-top: 10px;
text-align: center;
}
button {
width: 150px;
padding: 10px;
border: none;
border-radius: 5px;
background: #669999;
font-size: 16px;
color: #fff;
cursor: pointer;
}
button:hover {
background: #a3c2c2;
}
@media (min-width: 568px) {
.name-item, .city-item {
display: flex;
flex-wrap: wrap;
justify-content: space-between;
}
.name-item input, .name-item div {
width: calc(50% - 20px);
}
.name-item div input {
width:97%;}
.name-item div label {
display:block;
padding-bottom:5px;
}
}
</style>
</head>
<body>
<div class="testbox">
<form action="/">
<div class="banner">
<h1>Payment Form</h1>
<img src = "https://source.unsplash.com/random/1400x300"alt="My God">
</div>
<div class="colums">
<div class="item">
<label for="fname"> First Name<span>*</span></label>
<input id="fname" type="text" name="fname" required/>
</div>
<div class="item">
<label for="lname"> Last Name<span>*</span></label>
<input id="lname" type="text" name="lname" required/>
</div>
<div class="item">
<label for="address1">Current Address<span>*</span></label>
<input id="address1" type="text" name="address1" required/>
</div>
<div class="item">
<label for="address2"> Secondry Address<span>*</span></label>
<input id="address2" type="text" name="address2" required/>
</div>
<div class="item">
<label for="state">State<span>*</span></label>
<input id="state" type="text" name="state" required/>
</div>
<div class="item">
<label for="zip">Zip/Postal Code<span>*</span></label>
<input id="zip" type="text" name="zip" required/>
</div>
<div class="item">
<label for="city">City<span>*</span></label>
<input id="city" type="text" name="city" required/>
</div>
<div class="item">
<label for="eaddress">Email Address<span>*</span></label>
<input id="eaddress" type="text" name="eaddress" required/>
</div>
<div class="item">
<label for="phone">Phone<span>*</span></label>
<input id="phone" type="tel" name="phone" required/>
</div>
<div class="item">
<label for="Amount willing to Donate">Amount You are willing to pay</label>
<select name="Amount willing to Donate" id="Amount willing to Donate" required>
<option value="5-10">Rs50-Rs1000</option>
<option value="11-20">Rs1000-Rs 10,000</option>
<option value="21-50">Rs10,000-Rs50,000</option>
<option value="50+">Rs50,000+</option>
</select>
</div>
</div>
<div class="question">
<label>Preferred Method of Payment</label>
<div class="question-answer">
<div>
<input type="radio" value="none" id="radio_1" name="type"/>
<label for="radio_1" class="radio"><span>Credit card</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_2" name="type"/>
<label for="radio_2" class="radio"><span>Net Banking</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_3" name="type"/>
<label for="radio_3" class="radio"><span>PayTm</span></label>
</div>
</div>
</div>
<div class="question">
<label>Preferred way to contact </label>
<div class="question-answer">
<div>
<input type="radio" value="none" id="radio_4" name="contact"/>
<label for="radio_4" class="radio"><span>Phone</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_5" name="contact"/>
<label for="radio_5" class="radio"><span>Email</span></label>
</div>
<div>
<input type="radio" value="none" id="radio_6" name="contact"/>
<label for="radio_6" class="radio"><span>Any</span></label>
</div>
</div>
</div>
<h2>Terms and Conditions</h2>
<input type="checkbox" name="checkbox1">
<label>You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.Also By filling this form you agree that you are willing to Donate money to RKU Consultants.Thus the entiltement to use that money completely lies in the hands of RKU Consultants. We from all our teams want to thank you for your generosity.This nation and their people will always be in debt of people like you.</label>
<div class="btn-block">
<button type="submit" href="/">Submit</button>
</div>
</form>
</div>
</body>
</html>