Bootstrap Credit card payment form


	<div class="container">
	<div class="row-fluid">
      <form class="form-horizontal">
        <fieldset>
          <div id="legend">
            <legend class="">Payment</legend>
          </div>
     
          <!-- Name -->
          <div class="control-group">
            <label class="control-label" for="username">Card Holder's Name</label>
            <div class="controls">
              <input type="text" id="username" name="username" placeholder="" class="input-xlarge">
            </div>
          </div>
     
          <!-- Card Number -->
          <div class="control-group">
            <label class="control-label" for="email">Card Number</label>
            <div class="controls">
              <input type="text" id="email" name="email" placeholder="" class="input-xlarge">
            </div>
          </div>
     
          <!-- Expiry-->
          <div class="control-group">
            <label class="control-label" for="password">Card Expiry Date</label>
            <div class="controls">
              <select class="span3" name="expiry_month" id="expiry_month">
                <option>
                <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)1
                <option value="11">Nov (11)
                <option value="12">Dec (12)
              </select>
              <select class="span2" 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>
     
          <!-- CVV -->
          <div class="control-group">
            <label class="control-label" for="password_confirm">Card CVV</label>
            <div class="controls">
              <input type="password" id="password_confirm" name="password_confirm" placeholder="" class="span2">
            </div>
          </div>
     
          <!-- Save card -->
          <div class="control-group">
            <div class="controls">
              <label class="checkbox" for="save_card">
                <input type="checkbox" id="save_card" value="option1">
                Save card on file?
              </label>
            </div>
          </div>
     
          <!-- Submit -->
          <div class="control-group">
            <div class="controls">
              <button class="btn btn-success">Pay Now</button>
            </div>
          </div>
     
        </fieldset>
      </form>
    </div>
</div>
	<script type="text/javascript">
	
	</script>