<link href="https://fonts.googleapis.com/css?family=Open+Sans" rel="stylesheet">
<script src="assets/jquery.payform.min.js" charset="utf-8"></script>

<div id="$name" class="creditCardForm">
            <div class="heading">
                <h1>Confirm Purchase</h1>
            </div>
            <div class="payment">
                <form>
                    <div class="form-group owner">
                        <label for="owner">Owner</label>
                        <input type="text" class="form-control" id="owner">
                    </div>
                    <div class="form-group CVV">
                        <label for="cvv">CVV</label>
                        <input type="text" class="form-control" id="cvv">
                    </div>
                    <div class="form-group" id="card-number-field">
                        <label for="cardNumber">Card Number</label>
                        <input type="text" class="form-control" id="cardNumber">
                    </div>
                    <div class="form-group" id="expiration-date">
                        <label>Expiration Date</label>
                        <select>
                            <option value="01">January</option>
                            <option value="02">February </option>
                            <option value="03">March</option>
                            <option value="04">April</option>
                            <option value="05">May</option>
                            <option value="06">June</option>
                            <option value="07">July</option>
                            <option value="08">August</option>
                            <option value="09">September</option>
                            <option value="10">October</option>
                            <option value="11">November</option>
                            <option value="12">December</option>
                        </select>
                        <select>
                            <option value="23"> 2023</option>
                            <option value="24"> 2024</option>
                            <option value="25"> 2025</option>
                            <option value="26"> 2026</option>
                            <option value="27"> 2027</option>
                            <option value="28"> 2028</option>
                        </select>
                    </div>
                    <div class="form-group" id="credit_cards">
                        <img src="assets/visa.jpg" id="visa">
                        <img src="assets/mastercard.jpg" id="mastercard">
                        <img src="assets/amex.jpg" id="amex">
                    </div>
                    <div class="form-group" id="pay-now">
                        <button type="submit" class="btn btn-default" id="confirm-purchase">Confirm</button>
                    </div>
                </form>
            </div>
        </div>