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payment.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>Payment Form</title>
<link href="payment.css" rel="stylesheet">
<link href="https://stackpath.bootstrapcdn.com/font-awesome/4.7.0/css/font-awesome.min.css" rel="stylesheet"
integrity="sha384-wvfXpqpZZVQGK6TAh5PVlGOfQNHSoD2xbE+QkPxCAFlNEevoEH3Sl0sibVcOQVnN" crossorigin="anonymous">
<link rel="stylesheet" href="payment.css">
</head>
<body>
<div class="wrapper">
<h2>Payment Form</h2>
<form method="POST">
<h4>Account</h4>
<div class="input-group">
<div class="input-box">
<input type="text" placeholder="Full Name" required class="name">
<i class="fa fa-user icon"></i>
</div>
<div class="input-box">
<input type="text" placeholder="Nick Name" required class="name">
<i class="fa fa-user icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="email" placeholder="Email Adress" required class="name">
<i class="fa fa-envelope icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<h4> Date of Birth</h4>
<input type="text" placeholder="DD" class="dob">
<input type="text" placeholder="MM" class="dob">
<input type="text" placeholder="YYYY" class="dob">
</div>
<div class="input-box">
<h4> Gender</h4>
<input type="radio" id="b1" name="gendar" checked class="radio">
<label for="b1">Male</label>
<input type="radio" id="b2" name="gendar" class="radio">
<label for="b2">Female</label>
</div>
</div>
<div class="input-group">
<div class="input-box">
<h4>Payment Details</h4>
<input type="radio" name="pay" id="bc1" checked class="radio">
<label for="bc1"><span><i class="fa fa-cc-visa"></i> Credit Card</span></label>
<input type="radio" name="pay" id="bc2" class="radio">
<label for="bc2"><span><i class="fa fa-cc-paypal"></i> Paypal</span></label>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="tel" placeholder="Card Number" required class="name">
<i class="fa fa-credit-card icon"></i>
</div>
</div>
<div class="input-group">
<div class="input-box">
<input type="tel" placeholder="Card CVC" required class="name">
<i class="fa fa-user icon"></i>
</div>
<div class="input-box">
<select>
<option>01 jun</option>
<option>02 jun</option>
<option>03 jun</option>
</select>
<select>
<option>2020</option>
<option>2021</option>
<option>2022</option>
</select>
</div>
</div>
<div class="input-group">
<div class="input-box">
<button type="submit">PAY NOW</button>
</div>
</div>
</form>
</div>
</body>
</html>