Bootstrap Simple Credit Card Form


	<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 value="01">Jan (01)
                <option value="02">Feb (02)
                <option value="03">Mar (03)
                <option value="04">Apr (04)
                <option value="05">May (05)
                <option value="06">June (06)
                <option value="07">July (07)
                <option value="08">Aug (08)
                <option value="09">Sep (09)
                <option value="10">Oct (10)
                <option value="11">Nov (11)
                <option value="12">Dec (12)
              </select>
            </div>
            <div class="col-xs-3">
              <select class="form-control" name="expiry-year">
                <option value="13">2013
                <option value="14">2014
                <option value="15">2015
                <option value="16">2016
                <option value="17">2017
                <option value="18">2018
                <option value="19">2019
                <option value="20">2020
                <option value="21">2021
                <option value="22">2022
                <option value="23">2023
              </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>
	<script type="text/javascript">
	
	</script>