Card Holder's Name

{!! Form::text('card_firstname','',array('pattern'=>'\w+.*','required','placeholder'=>'First name','title'=>'Fill your First name','class'=>'form-control')) !!}

{!! Form::text('card_lastname','',array('pattern'=>'\w+.*','required','placeholder'=>'Last name','title'=>'Fill your Last name', 'class'=>'form-control')) !!}

Card Number

{!! Form::text('card_no1','',array('id'=>'card_no1','pattern'=>'\d{4}','required','class'=>'form-control','title'=>'First four digits','rel'=>'1','autocomplete'=>'off','maxlength'=>'4')) !!}

{!! Form::text('card_no2','',array('id'=>'card_no2','pattern'=>'\d{4}','required','class'=>'form-control','title'=>'Second four digits','rel'=>'1','autocomplete'=>'off','maxlength'=>'4')) !!}

{!! Form::text('card_no3','',array('id'=>'card_no3','pattern'=>'\d{4}','required','class'=>'form-control','title'=>'Third four digits','rel'=>'1','autocomplete'=>'off','maxlength'=>'4')) !!}

{!! Form::text('card_no4','',array('id'=>'card_no4','pattern'=>'\d{4}','required','class'=>'form-control','title'=>'Fourth four digits','rel'=>'1','autocomplete'=>'off','maxlength'=>'4')) !!}

Card Expiry Date

{!! Form::select('card_month',array('0' => 'Select one')+App\Models\Country::displayExpirationMonth(),date('m'),array('id'=>'card_month', 'class'=>'form-control', 'onchange'=>'focusYear()')) !!}

{!! Form::select('card_year',array('0' => 'Select one')+App\Models\Country::displayExpirationYear(),date('Y'),array('id'=>'card_year','class'=>'form-control', 'onchange'=>'focusCVV()')) !!}

Card CVV

{!! Form::text('card_cvv','',array('id'=>'card_cvv','required','class'=>'form-control','title'=>'Three or Four digits at back of your card','autocomplete'=>'off','maxlength'=>'4')) !!}

{!! Html::image('_front/assets/images/card-details.png') !!}