<html><head> <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1"> <script type="text/javascript" src="http://cdnjs.cloudflare.com/ajax/libs/jquery/2.0.3/jquery.min.js"></script> <script type="text/javascript" src="http://netdna.bootstrapcdn.com/bootstrap/3.3.4/js/bootstrap.min.js"></script> <link href="http://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.3.0/css/font-awesome.min.css" rel="stylesheet" type="text/css"> <link href="membership.css" rel="stylesheet" type="text/css"> </head><body> <div class="section"> <div class="container"> <div class="row"> <div class="col-md-2"></div> <div class="col-md-8"> <h3 class="text-left text-muted">Payment details</h3> <hr> <div class="page-header text-muted" contenteditable="true"> <h5>1 Year coworking membership (360 CHF)</h5> <h5> +2 free working days included (0 CHF)</h5> <div class="page-header text-muted"> <h5>Valid 01.01.2016 - 31.12.2016 </h5> <h5>Coworker Name : Nico Schottelius </h5> </div> </div> <div class="page-header text-muted"> <h3 class="text-right">Total : 360 CHF</h3> </div> <form role="form"> <div class="form-group"> <label class="control-label" for="exampleInputEmail1">Name*</label> <input class="form-control" id="exampleInputEmail1" placeholder="Enter name on card" type="email"> </div> <div class="form-group"> <label class="control-label" for="exampleInputPassword1">Card Number*</label> <input class="form-control" id="exampleInputPassword1" placeholder="Card Number" type="text"> </div> </form> <form role="form"> <div class="form-group"> <label class="control-label" for="exampleInputEmail1">Expiry Date*</label> <input class="form-control" id="exampleInputEmail1" placeholder="MM/YY" type="email"> </div> <div class="form-group"> <label class="control-label" for="exampleInputPassword1">CCV*</label> <input class="form-control" id="exampleInputPassword1" placeholder="CVV" type="password"> </div> <button type="submit" class="btn btn-block btn-primary">Submit</button> </form> <a class="btn btn-block btn-info">Cancel</a> </div> <div class="col-md-2"></div> </div> <div class="row"> <div class="col-md-11"> <br> <p class="text-center text-muted">Have probelm? Contact <a href="">help@digitalglarus.ch.</a> <br> <br> </p> </div> </div> </div> </div> </body></html>