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<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.1.3/css/bootstrap.min.css" integrity="sha384-MCw98/SFnGE8fJT3GXwEOngsV7Zt27NXFoaoApmYm81iuXoPkFOJwJ8ERdknLPMO" crossorigin="anonymous">
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/5.15.4/css/all.min.css">
<style>
.no-spinner::-webkit-outer-spin-button,
.no-spinner::-webkit-inner-spin-button {
-webkit-appearance: none;
margin: 0;
}
</style>
<title>FormsHTML5</title>
</head>
<body>
<div class="position-relative">
<div class="position-absolute top-50 start-50 translate-middle row justify-content-center mt-5 col-md-10 offset-md-1">
<div class="card">
<h5 class="card-header">Payment for example</h5>
<div class="card-body">
<div id="error-msg" class="alert alert-danger">Some fields are missing</div>
<form class="row g-3">
<div class="col-md-6">
<label for="cardNumber" class="form-label">Card #</label>
<input type="number" class="form-control no-spinner" id="cardNumber" placeholder="XXXX-XXXX-XXXX-XXXX" required>
</div>
<div class="col-md-2">
<label for="cvv" class="form-label">CVV</label>
<input type="number" class="form-control no-spinner" id="cvv" placeholder="0000" required>
</div>
<div class="col-md-4">
<label for="amount" class="form-label">Amount</label>
<div class="input-group mb-5">
<span class="input-group-text">$</span>
<input type="number" class="form-control no-spinner" id="amount" aria-label="Amount (to the nearest dollar)" required>
<span class="input-group-text">.00</span>
</div>
</div>
<div class="col-md-6">
<label for="firstName" class="form-label">First Name</label>
<input type="text" class="form-control" id="firstName" pattern="[A-Za-z]+" title="Only letters are allowed" required>
</div>
<div class="col-md-6">
<label for="lastName" class="form-label">Last Name</label>
<input type="text" class="form-control" id="lastName" pattern="[A-Za-z]+" title="Only letters are allowed" required>
</div>
<div class="col-md-4">
<label for="city" class="form-label">City</label>
<input type="text" class="form-control" id="city" pattern="[A-Za-z]+" title="Only letters are allowed" required>
</div>
<div class="col-md-4">
<label for="state" class="form-label">State</label>
<select class="form-control custom-select" id="state" required>
<option class="text-white bg-warning" disabled selected>Pick a state</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
<div class="col-md-2">
<label for="postalCode" class="form-label">Postal Code</label>
<input type="number" class="form-control no-spinner" id="postalCode" required>
</div>
<div class="col-md-6 pb-3">
<p>We accept:</p>
<div class="btn-group" data-toggle="buttons">
<label class="btn btn-secondary">
<input autocomplete="off" checked name="options" type="radio">
<i class="fab fa-cc-mastercard"></i>
</label>
<label class="btn btn-secondary">
<input autocomplete="off" name="options" type="radio">
<i class="fab fa-cc-visa"></i>
</label>
<label class="btn btn-secondary">
<input autocomplete="off" name="options" type="radio">
<i class="fab fa-cc-diners-club"></i>
</label>
<label class="btn btn-secondary">
<input autocomplete="off" name="options" type="radio">
<i class="fab fa-cc-amex"></i>
</label>
</div>
</div>
<div class="col-md-6">
<label for="message" class="form-label">Message</label>
<textarea class="form-control" id="message" rows="3"></textarea>
<small class="text-muted">Add any notes here.</small>
</div>
</form>
</div>
<div class="card-footer">
<div class="float-right">
<button class="btn btn-secondary" type="reset">Cancel</button>
<button id="sendForm" class="btn btn-primary" type="button">Send</button>
</div>
</div>
</div>
</div>
</div>
</body>
</html>