Website-Template/Payment Form/payment_form.html at main · Diptenusarkar/Website-Template · GitHub

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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>Payment  Form</title>
    <link href="https://cdn.jsdelivr.net/npm/bootstrap@5.2.2/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-Zenh87qX5JnK2Jl0vWa8Ck2rdkQ2Bzep5IDxbcnCeuOxjzrPF/et3URy9Bv1WTRi" crossorigin="anonymous">
  <script src="https://cdn.jsdelivr.net/npm/bootstrap@5.2.2/dist/js/bootstrap.bundle.min.js" integrity="sha384-OERcA2EqjJCMA+/3y+gxIOqMEjwtxJY7qPCqsdltbNJuaOe923+mo//f6V8Qbsw3" crossorigin="anonymous"></script>
  <script src="https://cdn.jsdelivr.net/npm/@popperjs/core@2.11.6/dist/umd/popper.min.js" integrity="sha384-oBqDVmMz9ATKxIep9tiCxS/Z9fNfEXiDAYTujMAeBAsjFuCZSmKbSSUnQlmh/jp3" crossorigin="anonymous"></script>
<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.2.2/dist/js/bootstrap.min.js" integrity="sha384-IDwe1+LCz02ROU9k972gdyvl+AESN10+x7tBKgc9I5HFtuNz0wWnPclzo6p9vxnk" crossorigin="anonymous"></script>
<link rel="stylesheet" href="styles.css">
</head>
<body>
    <form action="" class="">
        <h1 class="text-center">Payment Form</h1>
        <p>Required Fields are followed by *</p>

        <hr>
        <h2>Contact Information</h2>
        <p>Name:* <input type="text" name="name" required ></p>
        <fieldset>
          <div class="">
            <legend>Gender*</legend>
            <p>
            Male <input type="radio" name="gender" id="male" required>
            Female <input type="radio" name="gender" id="female" required>
           </p>
          </div>
        </fieldset>

        <p> Address : <br>
          <textarea name="address" id="address" cols="50" rows="5"></textarea></p>
        <p> Email * : <input type="email" name="email" id="email" required></p>
        <p> Pincode * : <input type="number" name="pincode" id="pincode" required></p>

        <hr>

        <h2 class="text-center">Payment Information</h2>

        <p>Card Type:*
            <select name="card_type" id="card_type" required>
                <option value="">--Select a Card Type></option>
                <option value="visa">Visa</option>
                <option value="rupay">Rupay</option>
                <option value="mastercard">Mastercard</option>
            </select>
        </p>
        <p>
            Card Number * <input type="number" name="card_number" id="card_number" required>
        </p>
        <p>
            Expiration Date:* <input type="date" name="exp_date" id="exp_date" required>
        </p>
        <p>
            CVV * <input type="password" name="cvv" id="cvv" required>
        </p>
        <div class="submit">
                 <input class="btn btn-outline-dark btn-lg" type="submit" value="Pay Now">
        </div>

    </form>
</body>
</html>