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index.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
<title>Document</title>
<link
href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css"
rel="stylesheet"
integrity="sha384-QWTKZyjpPEjISv5WaRU9OFeRpok6YctnYmDr5pNlyT2bRjXh0JMhjY6hW+ALEwIH"
crossorigin="anonymous"
/>
</head>
<body>
<div class="card m-5">
<div class="card-header">
<h4>Payment form example</h4>
</div>
<div class="card-body">
<form>
<div class="mb-3">
<div class="p-3 border rounded-3 alert alert-danger">
Some fields are missing
</div>
<div class="row">
<div class="col-4">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>Card #</label
>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
placeholder="XXXXXXXXXXXXXXX"
/>
</div>
</div>
<div class="col-4">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>CVC#</label
>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
placeholder="0000"
/>
</div>
</div>
<div class="col-4">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>Amount</label
>
<div class="d-flex">
<p>$</p>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
placeholder="Amount"
/>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>First Name</label
>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
/>
</div>
</div>
<div class="col-6">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>Last Name</label
>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
/>
</div>
</div>
</div>
<div class="row">
<div class="col-6">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>City</label
>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
/>
</div>
</div>
<div class="col-3">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>State</label
>
<select
class="form-select"
aria-label="Default select example"
>
<option selected>Pick a state</option>
</select>
</div>
</div>
<div class="col-3">
<div class="mb-3">
<label for="exampleInputEmail1" class="form-label"
>Postal Code</label
>
<input
type="email"
class="form-control"
id="exampleInputEmail1"
aria-describedby="emailHelp"
/>
</div>
</div>
</div>
<div class="row">
<div class="col-6 d-flex flex-column">
<label for="exampleFormControlTextarea1" class="form-label"
>We accept:</label
>
<div class="d-flex">
<div class="border rounded-3 text-bg-secondary p-3">
<div class="d-flex gap-4">
<div class="">
<input type="radio" checked />
<i class="fa-brands fa-cc-mastercard"></i>
</div>
<div class="">
<input type="radio" />
<i class="fa-brands fa-cc-visa"></i>
</div>
<div class="">
<input type="radio" />
<i class="fa-brands fa-cc-diners-club"></i>
</div>
<div class="">
<input type="radio" />
<i class="fa-brands fa-cc-amex"></i>
</div>
</div>
</div>
</div>
</div>
<div class="col-6">
<div class="mb-3">
<label for="exampleFormControlTextarea1" class="form-label"
>Message</label
>
<textarea
class="form-control"
id="exampleFormControlTextarea1"
rows="3"
></textarea>
<p>Add any notes here.</p>
</div>
</div>
</div>
</div>
</form>
</div>
<div
class="card-footer text-body-secondary d-flex justify-content-end gap-3"
>
<a href="#" class="btn btn-secondary">Cancel</a>
<a href="#" class="btn btn-primary">Send</a>
</div>
</div>
<script
src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.bundle.min.js"
integrity="sha384-YvpcrYf0tY3lHB60NNkmXc5s9fDVZLESaAA55NDzOxhy9GkcIdslK1eN7N6jIeHz"
crossorigin="anonymous"
></script>
<script
src="https://kit.fontawesome.com/072e5df971.js"
crossorigin="anonymous"
></script>
</body>
</html>