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index.html
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<!doctype html>
<html lang="en">
<head>
<title>HTML 5 Form</title>
<!-- Required meta tags -->
<meta charset="utf-8" />
<meta
name="viewport"
content="width=device-width, initial-scale=1, shrink-to-fit=no"
/>
<link
rel="stylesheet"
href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/6.0.0-beta3/css/all.min.css"
/>
<!-- Bootstrap CSS v5.2.1 -->
<link
href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css"
rel="stylesheet"
integrity="sha384-T3c6CoIi6uLrA9TneNEoa7RxnatzjcDSCmG1MXxSR1GAsXEV/Dwwykc2MPK8M2HN"
crossorigin="anonymous"
/>
</head>
<body>
<div class="wrapper mt-5">
<form action="">
<div class="container p-20 rounded">
<div class="card text-center">
<div class="card-header d-flex">
<h1>Payment form example</h1>
</div>
<div class="card-body">
<div class="alert d-flex alert-danger" role="alert">
Some fields are missing
</div>
<!-- inputs -->
<div class="container">
<div class="row">
<div class="mb-3 col-6">
<label for="exampleInputNumber" class="form-label d-flex">Card#</label>
<input type="tel" inputmode="numeric" maxlength="19" class="form-control" id="exampleInputNumber" placeholder="XXXX XXXX XXXX XXXX" aria-describedby="" required>
</div>
<div class="mb-3 col-3">
<label for="exampleInputCVC" class="form-label d-flex " >CVC#</label>
<input type="tel" inputmode="numeric" class="form-control" maxlength="3" id="exampleInputCVC" placeholder="000" aria-describedby="" required>
</div>
<div class="mb-3 col-3">
<label for="exampleInputAmount" class="form-label d-flex">Amount</label>
<input type="tel" inputmode="numeric" class="form-control" id="exampleInputAmount" placeholder="$ Amount" aria-describedby="" required>
</div>
</div>
<div class="row">
<div class="mb-3 col-6">
<label for="exampleInputFirstName" class="form-label d-flex">First Name</label>
<input type="email" class="form-control" id="exampleInputFirstName" aria-describedby="" required>
</div>
<div class="mb-3 col-6">
<label for="exampleInputLastName" class="form-label d-flex">Last Name</label>
<input type="email" class="form-control" id="exampleInputLastName" aria-describedby="" required>
</div>
</div>
<div class="row">
<div class="mb-3 col-6">
<label for="exampleInputCity" class="form-label d-flex">City</label>
<input type="email" class="form-control" id="exampleInputCity" aria-describedby="" required>
</div>
<div class="mb-3 col-3">
<label for="exampleInputFirstState" class="form-label d-flex">State</label>
<select class="form-select" aria-label="Default select example" required>
<option selected>Pick a State</option>
<option value="1">State One</option>
<option value="2">State Two</option>
<option value="3">State Three</option>
</select>
</div>
<div class="mb-3 col-3">
<label for="exampleInputFirstCode" class="form-label d-flex">Postal Code</label>
<input type="text" class="form-control" maxlength="15" id="exampleInputFirstCode" aria-describedby="" required>
</div>
</div>
<div class="row">
<div class=" col-6">
<p class="d-flex">We accept:</p>
<div class="d-flex bg-secondary rounded p-1 w-50">
<div class="form-check d-flex justify-content m-0 p-1">
<input class="form-check-input mx-1 " type="radio" name="exampleRadios" id="exampleRadios1" value="option1" checked>
<label class="form-check-label " for="exampleRadios1">
<i class="fab fa-cc-visa fa-2x"></i> <!-- Visa -->
</label>
</div>
<div class="form-check d-flex justify-content m-0 p-1">
<input class="form-check-input mx-1 " type="radio" name="exampleRadios" id="exampleRadios2" value="option2" checked>
<label class="form-check-label" for="exampleRadios2">
<i class="fab fa-cc-diners-club fa-2x"></i> <!-- Diners Club -->
</label>
</div>
<div class="form-check d-flex justify-content m-0 p-1">
<input class="form-check-input mx-1 " type="radio" name="exampleRadios" id="exampleRadios3" value="option3" checked>
<label class="form-check-label" for="exampleRadios3">
<i class="fab fa-cc-mastercard fa-2x"></i> <!-- Mastercard -->
</label>
</div>
<div class="form-check d-flex justify-content m-0 p-1">
<input class="form-check-input mx-1" type="radio" name="exampleRadios" id="exampleRadios4" value="option4" checked>
<label class="form-check-label" for="exampleRadios4">
<i class="fab fa-cc-amex fa-2x"></i> <!-- American Express -->
</label>
</div>
</div>
</div>
<div class="mb-3 col-6">
<div class="form-group">
<label class="d-flex" for="comment">Message</label>
<textarea class="form-control" rows="5" id="comment"></textarea>
<p class="d-flex fs-6 fw-lighter">Add any notes here</p>
</div>
</div>
</div>
</div>
</div>
<div class="card-footer text-muted text-end p-3">
<button type="button" class="btn btn-secondary">Cancel</button>
<button type="button" class="btn btn-primary">Send</button>
</div>
</div>
</div>
</form>
</div>
<script
src="https://cdn.jsdelivr.net/npm/@popperjs/[email protected]/dist/umd/popper.min.js"
integrity="sha384-I7E8VVD/ismYTF4hNIPjVp/Zjvgyol6VFvRkX/vR+Vc4jQkC+hVqc2pM8ODewa9r"
crossorigin="anonymous"
></script>
<script
src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.min.js"
integrity="sha384-BBtl+eGJRgqQAUMxJ7pMwbEyER4l1g+O15P+16Ep7Q9Q+zqX6gSbd85u4mG4QzX+"
crossorigin="anonymous"
></script>
</body>
</html>