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41 lines (41 loc) · 1.55 KB
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<!DOCTYPE html>
<html lang="en">
<head>
<title>PAYMENT FORM</title>
<link rel="stylesheet" href="stylee.css">
</head>
<body>
<div class="container">
<form action="">
<h1 class="main">Payment Form</h1>
<p>*-Required Fields</p>
<h2>Personal Details</h2>
<p>Name: *<input type="text" name="name" required></p>
<legend>Gender *</legend>
<p>
Male <input type="radio" name="gender" id="male" required> Female <input type="radio" name="gender" id="female" required>
</p>
<p>Age: *<input type="number" name="age" id="age" required></p>
<p>Email: *<input type="email" name="email" id="email" required></p>
<p>Pincode: *<input type="number" name="pin" id="pin" required></p>
<h2>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="master card">Master Card</option>
</select>
</p>
<p>
Card Number: *<input type="number" name="card_no" id="card_no" 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>
<input type="submit" value="Pay Now">
</form>
</div>
</body>
</html>