.container
  form
    .row
      h4 Account
      .input-group.input-group-icon
        input(type="text", placeholder="Full Name")
        .input-icon
          i.fa.fa-user
      .input-group.input-group-icon
        input(type="email", placeholder="Email Adress")
        .input-icon
          i.fa.fa-envelope
      .input-group.input-group-icon
        input(type="password", placeholder="Password")
        .input-icon
          i.fa.fa-key
    .row
      .col-half
        h4 Date of Birth
        .input-group
          .col-third
            input(type="text", placeholder="DD")
          .col-third
            input(type="text", placeholder="MM")
          .col-third
            input(type="text", placeholder="YYYY")
      .col-half
        h4 Gender
        .input-group
          input#gender-male(type="radio", name="gender", value="male")
          label(for="gender-male") Male
          input#gender-female(type="radio", name="gender", value="female")
          label(for="gender-female") Female
    .row
      h4 Payment Details
      .input-group
        input#payment-method-card(
          type="radio",
          name="payment-method",
          value="card",
          checked="true"
        )
        label(for="payment-method-card")
          span
            i.fa.fa-cc-visa
            | Credit Card
        input#payment-method-paypal(
          type="radio",
          name="payment-method",
          value="paypal"
        )
        label(for="payment-method-paypal") 
          span
            i.fa.fa-cc-paypal
            | Paypal
      .input-group.input-group-icon
        input(type="text", placeholder="Card Number")
        .input-icon
          i.fa.fa-credit-card
      .col-half
        .input-group.input-group-icon
          input(type="text", placeholder="Card CVC")
          .input-icon
            i.fa.fa-user
      .col-half
        .input-group
          select
            option 01 Jan
            option 02 Jan
          select
            option 2015
            option 2016
    .row
      h4 Terms and Conditions
      .input-group
        input#terms(type="checkbox")
        label(for="terms") I accept the terms and conditions for signing up to this service, and hereby confirm I have read the privacy policy.
View Compiled
/* 64ac15 */
*,
*:before,
*:after {
  box-sizing: border-box;
}
body {
  padding: 1em;
  font-family: "Open Sans", "Helvetica Neue", Helvetica, Arial, sans-serif;
  font-size: 15px;
  color: #b9b9b9;
  background-color: #e3e3e3;
}
h4 {
  color: #f0a500;
}
input,
input[type="radio"] + label,
input[type="checkbox"] + label:before,
select option,
select {
  width: 100%;
  padding: 1em;
  line-height: 1.4;
  background-color: #f9f9f9;
  border: 1px solid #e5e5e5;
  border-radius: 3px;
  -webkit-transition: 0.35s ease-in-out;
  -moz-transition: 0.35s ease-in-out;
  -o-transition: 0.35s ease-in-out;
  transition: 0.35s ease-in-out;
  transition: all 0.35s ease-in-out;
}
input:focus {
  outline: 0;
  border-color: #bd8200;
}
input:focus + .input-icon i {
  color: #f0a500;
}
input:focus + .input-icon:after {
  border-right-color: #f0a500;
}
input[type="radio"] {
  display: none;
}
input[type="radio"] + label,
select {
  display: inline-block;
  width: 50%;
  text-align: center;
  float: left;
  border-radius: 0;
}
input[type="radio"] + label:first-of-type {
  border-top-left-radius: 3px;
  border-bottom-left-radius: 3px;
}
input[type="radio"] + label:last-of-type {
  border-top-right-radius: 3px;
  border-bottom-right-radius: 3px;
}
input[type="radio"] + label i {
  padding-right: 0.4em;
}
input[type="radio"]:checked + label,
input:checked + label:before,
select:focus,
select:active {
  background-color: #f0a500;
  color: #fff;
  border-color: #bd8200;
}
input[type="checkbox"] {
  display: none;
}
input[type="checkbox"] + label {
  position: relative;
  display: block;
  padding-left: 1.6em;
}
input[type="checkbox"] + label:before {
  position: absolute;
  top: 0.2em;
  left: 0;
  display: block;
  width: 1em;
  height: 1em;
  padding: 0;
  content: "";
}
input[type="checkbox"] + label:after {
  position: absolute;
  top: 0.45em;
  left: 0.2em;
  font-size: 0.8em;
  color: #fff;
  opacity: 0;
  font-family: FontAwesome;
  content: "\f00c";
}
input:checked + label:after {
  opacity: 1;
}
select {
  height: 3.4em;
  line-height: 2;
}
select:first-of-type {
  border-top-left-radius: 3px;
  border-bottom-left-radius: 3px;
}
select:last-of-type {
  border-top-right-radius: 3px;
  border-bottom-right-radius: 3px;
}
select:focus,
select:active {
  outline: 0;
}
select option {
  background-color: #f0a500;
  color: #fff;
}
.input-group {
  margin-bottom: 1em;
  zoom: 1;
}
.input-group:before,
.input-group:after {
  content: "";
  display: table;
}
.input-group:after {
  clear: both;
}
.input-group-icon {
  position: relative;
}
.input-group-icon input {
  padding-left: 4.4em;
}
.input-group-icon .input-icon {
  position: absolute;
  top: 0;
  left: 0;
  width: 3.4em;
  height: 3.4em;
  line-height: 3.4em;
  text-align: center;
  pointer-events: none;
}
.input-group-icon .input-icon:after {
  position: absolute;
  top: 0.6em;
  bottom: 0.6em;
  left: 3.4em;
  display: block;
  border-right: 1px solid #e5e5e5;
  content: "";
  -webkit-transition: 0.35s ease-in-out;
  -moz-transition: 0.35s ease-in-out;
  -o-transition: 0.35s ease-in-out;
  transition: 0.35s ease-in-out;
  transition: all 0.35s ease-in-out;
}
.input-group-icon .input-icon i {
  -webkit-transition: 0.35s ease-in-out;
  -moz-transition: 0.35s ease-in-out;
  -o-transition: 0.35s ease-in-out;
  transition: 0.35s ease-in-out;
  transition: all 0.35s ease-in-out;
}
.container {
  max-width: 38em;
  padding: 1em 3em 2em 3em;
  margin: 0em auto;
  background-color: #fff;
  border-radius: 4.2px;
  box-shadow: 0px 3px 10px -2px rgba(0, 0, 0, 0.2);
}
.row {
  zoom: 1;
}
.row:before,
.row:after {
  content: "";
  display: table;
}
.row:after {
  clear: both;
}
.col-half {
  padding-right: 10px;
  float: left;
  width: 50%;
}
.col-half:last-of-type {
  padding-right: 0;
}
.col-third {
  padding-right: 10px;
  float: left;
  width: 33.33333333%;
}
.col-third:last-of-type {
  padding-right: 0;
}
@media only screen and (max-width: 540px) {
  .col-half {
    width: 100%;
    padding-right: 0;
  }
}
// INSPIRED BY SEB KAY'S 'SIGN UP FORM'
// https://dribbble.com/shots/1776663-Purple-Sign-Up-Form
// https://dribbble.com/shots/1779149--Free-PSD-Purple-Sign-Up-Form-Payment-Details
// @purple: #c68eaa;
// @green: #f0a500;
// #64ac15  bd8200

// #7ed321 light f0a500

External CSS

  1. https://maxcdn.bootstrapcdn.com/font-awesome/4.3.0/css/font-awesome.min.css

External JavaScript

  1. https://cdnjs.cloudflare.com/ajax/libs/jquery/2.1.3/jquery.min.js