<!doctype html>
<html>
<head>
<meta charset="utf-8">
<title>Untitled Document</title>
</head>

<body>
	<form action="charge.php" method="post">
    <input type="text" name="amount" placeholder="Enter Amount" readonly />
    <input type="text" name="cc_number" placeholder="Card Number" />
    <input type="text" name="expiry_month" placeholder="MM" maxlength="2" />
    <input type="text" name="expiry_year" placeholder="YYYY" maxlength="4" />
    <input type="text" name="cvv" placeholder="CVV" />
    <input type="submit" name="submit" value="Submit" />
</form>
</body>
</html>