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              <body>
	<div class="main">
		<div class="leftside">
			<h2>Payment Information</h2>
			<form action="" method="get">
				<div class="input-group">
					<label for="name">Cardholder Name</label>
					<input type="text" name="name" value="" placeholder="Type your name here" class="form-control" >
				</div>
				<div class="input-group">
					<label for="cardno">Card Number</label>
					<input type="text" name="cardno" value="" maxlength="12" placeholder="Type card number" class="form-control">
				</div>
				<div class="exp-date">
					<fieldset>
						<legend>Expiration date</legend>
						<select name="exp-month"  class="exp-month">
							<option value="">Jan</option>
							<option value="">Feb</option>
							<option value="">Mar</option>
							<option value="">Apr</option>
							<option value="">May</option>
							<option value="">Jun</option>
							<option value="">Jul</option>
							<option value="">Aug</option>
							<option value="">Sep</option>
							<option value="">Oct</option>
							<option value="">Nov</option>
							<option value="">dec</option>
						</select>
						<select name="exp-year" class="exp-year">
							<option value="">2017</option>
							<option value="">2018</option>
							<option value="">2019</option>
							<option value="">2020</option>
							<option value="">2021</option>
							<option value="">2022</option>
							<option value="">2023</option>
							<option value="">2024</option>
							<option value="">2025</option>
						</select>
					</fieldset>
				</div>
				<div class="cvv">
					<label for="cvv">CVV</label>
					<input type="text" maxlength="3" name="cvv" value="" class="cvv-input" >
					<div class="help-icon"><i class="fa fa-question-circle"></i></div>
				</div>
				<div class="button">
					<input type="submit" name="pay" value="Make a Payment" class="pay" >
				</div>
			</form>
		</div>
		<div class="rightside">
			<div class="logo"><img src="http://webdesignerlab.com/demos/codepen-portfolio/dailyui-2/logo.png" alt=""></div>
			<h2>Summary</h2>
			<table>
				<tbody>
					<tr class="lined">
						<td>Item 1</td>
						<td>2 x $49.90</td>
					</tr>
					<tr>
						<td>Item 2</td>
						<td>1 x $55.25</td>
					</tr>
					<tr class="lined">
						<td>Total Purchases</td>
						<td>$155.05</td>
					</tr>
					<tr>
						<td>Shipping</td>
						<td>$10.90</td>
					</tr>
				</tbody>
			</table>
			<div class="total">TOTAL: $165.95</div>
		</div>
	</div>
</body>
            
          
!
            
              *, *::before, *::after {
  box-sizing: border-box;
}

body {
	background-image: url("http://webdesignerlab.com/demos/codepen-portfolio/dailyui-2/background.jpg");
	font-family: 'Open Sans', sans-serif;
	font-size: 14px;
}

h2 {
	text-align: center;
	font-weight: 300;
	color: #da6440;
	font-size: 1.8em;

}

.main {
	width: 60%;
	margin: 10% auto;
	display: flex;
}

.leftside, .rightside {
	background-color: #fff;
	padding: 40px;
	flex: 1; 
	color: #909090;
}

.leftside h2 {
	font-weight: 400;
	margin-top: 0;
}

.leftside form {
	margin: 30px auto;
	width: 80%;
	font-size: 90%;
}

.input-group {
	position: relative;
	margin: 20px 0;

}

.form-control {
	display: block;
	margin-top: 10px;
	width: 100%;
	line-height: 150%;
	font-size: 1.2em;
	border-radius: 5px;
	border: 1px solid #acacac;
	height: 40px;
	padding: 10px;
}

.exp-date {
	float: left;
	width: 80%;
}

.cvv {
	float: left;
	width: 20%;
	position: relative;
}

fieldset {
	border: none;
	padding: 0;
	margin: 0;
}

.exp-month, .exp-year {
	margin-top: 10px;
	width: 45%;
	line-height: 150%;
	font-size: 1.2em;
	border-radius: 5px;
	border: 1px solid #acacac;
	height: 40px;
	padding: 10px;
}

.cvv-input {
	display: block;
	margin-top: 10px;
	width: 100%;
	line-height: 150%;
	font-size: 1.2em;
	border-radius: 5px;
	border: 1px solid #acacac;
	height: 40px;
	padding: 10px;
}

.help-icon {
	position: absolute;
	top: 0;
	left: 65px;
}

.button {
	clear: both;
	padding-top: 30px;
}

input.pay {
	display: block;
	width: 100%;
	border-radius: 5px;
	background-color: #da6440;
	border: none;
	font-size: 16px;
	font-weight: 500;
	color: #fff;
	padding: 10px 0;
}


.rightside {
	background-color: rgba(34,34,34,.8);
	padding: 40px;
	color: #fff;
}

.rightside h2 {
	text-transform: uppercase;
	margin-top: 10%;
}

.rightside table {
	width: 100%;
	border-collapse:collapse;

}

.rightside table td {
	padding-bottom: 10px;
}

.lined td {
	border-top: 1px solid #fff;
	padding-top: 20px;
	margin: 0;
}

tr td:last-child {
	text-align: right;
}

.total {
	text-align: right;
	margin-top: 8%;
	font-weight: 600;
	font-size: 1.8em;
	color: #da6440;
}
            
          
!
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