Bootstrap Credit Card Payment form


	<div class="container">
  <div class="row">
    <div class="span12">
      <form class="form-horizontal span6">
        <fieldset>
          <legend>Payment</legend>
       
          <div class="control-group">
            <label class="control-label">Card Holder's Name</label>
            <div class="controls">
              <input type="text" class="input-block-level" pattern="\w+ \w+.*" title="Fill your first and last name" required="">
            </div>
          </div>
       
          <div class="control-group">
            <label class="control-label">Card Number</label>
            <div class="controls">
              <div class="row-fluid">
                <div class="span3">
                  <input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="First four digits" required="">
                </div>
                <div class="span3">
                  <input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="Second four digits" required="">
                </div>
                <div class="span3">
                  <input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="Third four digits" required="">
                </div>
                <div class="span3">
                  <input type="text" class="input-block-level" autocomplete="off" maxlength="4" pattern="\d{4}" title="Fourth four digits" required="">
                </div>
              </div>
            </div>
          </div>
       
          <div class="control-group">
            <label class="control-label">Card Expiry Date</label>
            <div class="controls">
              <div class="row-fluid">
                <div class="span9">
                  <select class="input-block-level">
                    <option>January
                    <option>...
                    <option>December
                  </select>
                </div>
                <div class="span3">
                  <select class="input-block-level">
                    <option>2013
                    <option>...
                    <option>2015
                  </select>
                </div>
              </div>
            </div>
          </div>
       
          <div class="control-group">
            <label class="control-label">Card CVV</label>
            <div class="controls">
              <div class="row-fluid">
                <div class="span3">
                  <input type="text" class="input-block-level" autocomplete="off" maxlength="3" pattern="\d{3}" title="Three digits at back of your card" required="">
                </div>
                <div class="span8">
                  <!-- screenshot may be here -->
                </div>
              </div>
            </div>
          </div>
       
          <div class="form-actions">
            <button type="submit" class="btn btn-primary">Submit</button>
            <button type="button" class="btn">Cancel</button>
          </div>
        </fieldset>
      </form>
    </div>
  </div>
</div>
	<script type="text/javascript">
	
	</script>