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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Payment form example</title>
<!-- Bootstrap Styling link -->
<link href="https://cdn.jsdelivr.net/npm/bootstrap@5.0.2/dist/css/bootstrap.min.css" rel="stylesheet"
integrity="sha384-EVSTQN3/azprG1Anm3QDgpJLIm9Nao0Yz1ztcQTwFspd3yD65VohhpuuCOmLASjC" crossorigin="anonymous">
<!-- Fontawesome link (For the icons) -->
<script src="https://kit.fontawesome.com/072e5df971.js" crossorigin="anonymous"></script>
</head>
<body>
<div class="container-fluid col-7 roundend mt-4">
<form>
<div class="card">
<div class="card-header">
<h1> Payment form example</h1>
</div>
<div class="card-body">
<div class="row">
<div class="alert alert-danger" role="alert">
A simple danger alert
</div>
</div>
<div class="row">
<div class="col-5">
<div class="mb-3">
<label for="">Card #</label>
<input type="text" class="form-control" placeholder="XXXXXXXXXX">
</div>
</div>
<div class="col-3">
<div class="mb-3">
<label for="" class="form-label">CVC #</label>
<input type="text" class="form-control" placeholder="0000">
</div>
</div>
<div class="col-4">
<div class="mb-3">
<label for="" class="form-label">Amount</label>
<input type="text" class="form-control" placeholder="Amount">
<h6></h6>
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="mb-3">
<label for="" class="form-label">First Name</label>
<input type="text" class="form-control">
</div>
</div>
<div class="col-6">
<div class="mb-3">
<label for="" class="form-label">Last Name</label>
<input type="text" class="form-control">
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="mb-3">
<label for="" class="form-label">City</label>
<input type="text" class="form-control">
</div>
</div>
<div class="col-3">
<div class="mb-3">
<label for="inputState" class="form-label">State</label>
<select id="inputState" class="form-select">
<option selected>Pick a State</option>
<option>...</option>
</select>
</div>
</div>
<div class="col-3">
<div class="mb-3">
<label for="" class="form-label">Postal code</label>
<input type="text" class="form-control">
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="mb-3">
<label for="" class="form-label">We accept</label>
<div class="bg-secondary col-6 rounded p-1">
<input type="radio" checked autocomplete="on"><i
class="fa-brands fa-cc-mastercard"></i>
<input type="radio"><i class="fa-brands fa-cc-visa"></i>
<input type="radio"><i class="fa-brands fa-cc-diners-club"></i>
<input type="radio"><i class="fa-brands fa-cc-discover"></i>
</div>
</div>
</div>
<div class="col-6 form group">
<label for="exampleFormControlTextarea1">Message</label>
<textarea class="form-control" id="exampleFormControlTextarea1" rows="3"></textarea>
<p>Add any notes here</p>
</div>
</div>
</div>
</div>
<div class="card-footer text-end">
<a href="#" class="btn btn-secondary">Cancel</a>
<a href="#" class="btn btn-primary">Send</a>
</div>
</div>
</form>
</div>
</body>