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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">
<title>Bootstrap demo</title>
<link href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css" rel="stylesheet"
integrity="sha384-QWTKZyjpPEjISv5WaRU9OFeRpok6YctnYmDr5pNlyT2bRjXh0JMhjY6hW+ALEwIH" crossorigin="anonymous">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/[email protected]/font/bootstrap-icons.min.css">
<link rel="stylesheet" type="text/css" href="styles.css">
<link
rel="stylesheet"
href="https://use.fontawesome.com/releases/v5.2.0/css/all.css"
integrity="sha384-hWVjflwFxL6sNzntih27bfxkr27PmbbK/iSvJ+a4+0owXq79v+lsFkW54bOGbiDQ"
crossorigin="anonymous"
/>
</head>
<body>
<div class="card m-3" style="width: 90rem;">
<div class="col-12">
<legend class="bg-secondary-subtle ps-3"><strong>Payment form example</strong></legend>
</div>
<form class="row g-3 px-3">
<div class="mx-1.5">
<div class="col-12 text-danger bg-danger bg-opacity-50 rounded py-2" style="height: 40px;">
<div class="ms-3">Some fields are missing</div>
</div>
</div>
<div class="col-5">
<label for="inputcard" class="form-label">Card #</label>
<input type="number" class="form-control" id="inputcard" placeholder="XXXXXXXXXXXXXXXX">
</div>
<div class="col-3">
<label for="inputCVC" class="form-label">CVC #</label>
<input type="number" class="form-control" id="inputCVC" placeholder="0000">
</div>
<div class="col-4">
<label for="inputAmount" class="form-label d-block">Amount</label>
<div class="input-group mb-3">
<span class="input-group-text">$</span>
<input type="text" class="form-control" aria-label="Amount (to the nearest dollar)">
</div>
</div>
<div class="col-6">
<label for="inputFName" class="form-label">First Name</label>
<input type="text" class="form-control" id="inputName">
</div>
<div class="col-6">
<label for="inputLName" class="form-label">Last Name</label>
<input type="text" class="form-control" id="inputPassword4">
</div>
<div class="col-6">
<label for="inputCity" class="form-label">City</label>
<input type="text" class="form-control" id="inputCity">
</div>
<div class="col-3">
<label for="inputState" class="form-label">State</label>
<select id="inputState" class="form-select">
<option selected>Pick a state</option>
<option>Alabama</option>
<option>Alaska</option>
<option>Arizona</option>
<option>Arkansas</option>
<option>California</option>
<option>Colorado</option>
<option>Connecticut</option>
<option>Delaware</option>
<option>Florida</option>
<option>Georgia</option>
<option>Hawaii</option>
<option>Idaho</option>
<option>Illinois</option>
<option>Indiana</option>
<option>Iowa</option>
<option>Kansas</option>
<option>Kentucky</option>
<option>Louisiana</option>
<option>Maine</option>
<option>Maryland</option>
<option>Massachusetts</option>
<option>Michigan</option>
<option>Minnesota</option>
<option>Mississippi</option>
<option>Missouri</option>
<option>Montana</option>
<option>Nebraska</option>
<option>Nevada</option>
<option>New Hampshire</option>
<option>New Jersey</option>
<option>New Mexico</option>
<option>New York</option>
<option>North Carolina</option>
<option>North Dakota</option>
<option>Ohio</option>
<option>Oklahoma</option>
<option>Oregon</option>
<option>Pennsylvania</option>
<option>Rhode Island</option>
<option>South Carolina</option>
<option>South Dakota</option>
<option>Tennessee</option>
<option>Texas</option>
<option>Utah</option>
<option>Vermont</option>
<option>Virginia</option>
<option>Washington</option>
<option>West Virginia</option>
<option>Wisconsin</option>
<option>Wyoming</option>
</select>
</div>
<div class="col-3">
<label for="inputZip" class="form-label">Postal Code</label>
<input type="number" class="form-control" id="inputZip">
</div>
<div class="col-3">
<label for="cardtype" class="form-label">We Accept</label>
<div class="bg-secondary rounded p-2">
<div class="form-check form-check-inline mx-3">
<input class="form-check-input" type="radio" name="flexRadioDefault" id="cardtype" value="option1">
<label class="form-check-label" for="inlineCheckbox1"><i class="fab fa-cc-mastercard"></i></label>
</div>
<div class="form-check form-check-inline mx-3">
<input class="form-check-input" type="radio" name="flexRadioDefault" id="cardtype" value="option2">
<label class="form-check-label" for="inlineCheckbox2"><i class="fab fa-cc-visa"></i></label>
</div>
<div class="form-check form-check-inline mx-3">
<input class="form-check-input" type="radio" name="flexRadioDefault" id="cardtype" value="option3">
<label class="form-check-label" for="inlineCheckbox3"><i class="fab fa-cc-discover"></i></label>
</div>
<div class="form-check form-check-inline mx-3">
<input class="form-check-input" type="radio" name="flexRadioDefault" id="cardtype" value="option4">
<label class="form-check-label" for="inlineCheckbox4"><i class="fab fa-cc-amex"></i></label>
</div>
</div>
</div>
<div class="col-3">
</div>
<div class="col-6">
<label for="message" class="form-label">Message</label>
<textarea class="form-control" id="message"></textarea>
</div>
</form>
<div class="bg-secondary-subtle p-3 mx-right d-flex justify-content-end">
<button type="reset" class="btn btn-secondary mx-2">Cancel</button>
<button type="submit" class="btn btn-primary">Send</button>
</div>
</div>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.bundle.min.js"
integrity="sha384-YvpcrYf0tY3lHB60NNkmXc5s9fDVZLESaAA55NDzOxhy9GkcIdslK1eN7N6jIeHz"
crossorigin="anonymous"></script>
</body>
</html>