<div class="container">
  <div class="py-5 text-center">
    
    <h2>Checkout form</h2>
    <p class="lead">Below is an example form built entirely with Bootstrap’s form controls. Each required form group has a validation state that can be triggered by attempting to submit the form without completing it.</p>
  </div>

  <div class="row">
    <div class="col-md-4 order-md-2 mb-4">
      <h4 class="d-flex justify-content-between align-items-center mb-3">
        <span class="text-muted">Your cart</span>
        <span class="badge badge-secondary badge-pill">3</span>
      </h4>
      <ul class="list-group mb-3">
        <li class="list-group-item d-flex justify-content-between lh-condensed">
          <div>
            <h6 class="my-0">Product name</h6>
            <small class="text-muted">Brief description</small>
          </div>
          <span class="text-muted">$12</span>
        </li>
        <li class="list-group-item d-flex justify-content-between lh-condensed">
          <div>
            <h6 class="my-0">Second product</h6>
            <small class="text-muted">Brief description</small>
          </div>
          <span class="text-muted">$8</span>
        </li>
        <li class="list-group-item d-flex justify-content-between lh-condensed">
          <div>
            <h6 class="my-0">Third item</h6>
            <small class="text-muted">Brief description</small>
          </div>
          <span class="text-muted">$5</span>
        </li>
        <li class="list-group-item d-flex justify-content-between bg-light">
          <div class="text-success">
            <h6 class="my-0">Promo code</h6>
            <small>EXAMPLECODE</small>
          </div>
          <span class="text-success">-$5</span>
        </li>
        <li class="list-group-item d-flex justify-content-between">
          <span>Total (USD)</span>
          <strong>$20</strong>
        </li>
      </ul>

      <form class="card p-2">
        <div class="input-group">
          <input type="text" class="form-control" placeholder="Promo code">
          <div class="input-group-append">
            <button type="submit" class="btn btn-secondary">Redeem</button>
          </div>
        </div>
      </form>
    </div>
    <div class="col-md-8 order-md-1">
      <h4 class="mb-3">Billing address</h4>
      <form class="needs-validation" novalidate>
        <div class="row">
          <div class="col-md-6 mb-3">
            <label for="firstName">First name</label>
            <input type="text" class="form-control" id="firstName" placeholder="" value="" required>
            <div class="invalid-feedback">
              Valid first name is required.
            </div>
          </div>
          <div class="col-md-6 mb-3">
            <label for="lastName">Last name</label>
            <input type="text" class="form-control" id="lastName" placeholder="" value="" required>
            <div class="invalid-feedback">
              Valid last name is required.
            </div>
          </div>
        </div>

        <div class="mb-3">
          <label for="username">Username</label>
          <div class="input-group">
            <div class="input-group-prepend">
              <span class="input-group-text">@</span>
            </div>
            <input type="text" class="form-control" id="username" placeholder="Username" required>
            <div class="invalid-feedback" style="width: 100%;">
              Your username is required.
            </div>
          </div>
        </div>

        <div class="mb-3">
          <label for="email">Email <span class="text-muted">(Optional)</span></label>
          <input type="email" class="form-control" id="email" placeholder="[email protected]">
          <div class="invalid-feedback">
            Please enter a valid email address for shipping updates.
          </div>
        </div>

        <div class="mb-3">
          <label for="address">Address</label>
          <input type="text" class="form-control" id="address" placeholder="1234 Main St" required>
          <div class="invalid-feedback">
            Please enter your shipping address.
          </div>
        </div>

        <div class="mb-3">
          <label for="address2">Address 2 <span class="text-muted">(Optional)</span></label>
          <input type="text" class="form-control" id="address2" placeholder="Apartment or suite">
        </div>

        <div class="row">
          <div class="col-md-5 mb-3">
            <label for="country">Country</label>
            <select class="custom-select d-block w-100" id="country" required>
              <option value="">Choose...</option>
              <option>United States</option>
            </select>
            <div class="invalid-feedback">
              Please select a valid country.
            </div>
          </div>
          <div class="col-md-4 mb-3">
            <label for="state">State</label>
            <select class="custom-select d-block w-100" id="state" required>
              <option value="">Choose...</option>
              <option>California</option>
            </select>
            <div class="invalid-feedback">
              Please provide a valid state.
            </div>
          </div>
          <div class="col-md-3 mb-3">
            <label for="zip">Zip</label>
            <input type="text" class="form-control" id="zip" placeholder="" required>
            <div class="invalid-feedback">
              Zip code required.
            </div>
          </div>
        </div>
        <hr class="mb-4">
        <div class="custom-control custom-checkbox">
          <input type="checkbox" class="custom-control-input" id="same-address">
          <label class="custom-control-label" for="same-address">Shipping address is the same as my billing address</label>
        </div>
        <div class="custom-control custom-checkbox">
          <input type="checkbox" class="custom-control-input" id="save-info">
          <label class="custom-control-label" for="save-info">Save this information for next time</label>
        </div>
        <hr class="mb-4">

        <h4 class="mb-3">Payment</h4>

        <div class="d-block my-3">
          <div class="custom-control custom-radio">
            <input id="credit" name="paymentMethod" type="radio" class="custom-control-input" checked required>
            <label class="custom-control-label" for="credit">Credit card</label>
          </div>
          <div class="custom-control custom-radio">
            <input id="debit" name="paymentMethod" type="radio" class="custom-control-input" required>
            <label class="custom-control-label" for="debit">Debit card</label>
          </div>
          <div class="custom-control custom-radio">
            <input id="paypal" name="paymentMethod" type="radio" class="custom-control-input" required>
            <label class="custom-control-label" for="paypal">PayPal</label>
          </div>
        </div>
        <div class="row">
          <div class="col-md-6 mb-3">
            <label for="cc-name">Name on card</label>
            <input type="text" class="form-control" id="cc-name" placeholder="" required>
            <small class="text-muted">Full name as displayed on card</small>
            <div class="invalid-feedback">
              Name on card is required
            </div>
          </div>
          <div class="col-md-6 mb-3">
            <label for="cc-number">Credit card number</label>
            <input type="text" class="form-control" id="cc-number" placeholder="" required>
            <div class="invalid-feedback">
              Credit card number is required
            </div>
          </div>
        </div>
        <div class="row">
          <div class="col-md-3 mb-3">
            <label for="cc-expiration">Expiration</label>
            <input type="text" class="form-control" id="cc-expiration" placeholder="" required>
            <div class="invalid-feedback">
              Expiration date required
            </div>
          </div>
          <div class="col-md-3 mb-3">
            <label for="cc-cvv">CVV</label>
            <input type="text" class="form-control" id="cc-cvv" placeholder="" required>
            <div class="invalid-feedback">
              Security code required
            </div>
          </div>
        </div>
        <hr class="mb-4">
        <button class="btn btn-primary btn-lg btn-block" type="submit">Continue to checkout</button>
      </form>
    </div>
  </div>

  <footer class="my-5 pt-5 text-muted text-center text-small">
    <p class="mb-1">&copy; 2017-2019 Company Name</p>
    <ul class="list-inline">
      <li class="list-inline-item"><a href="#">Privacy</a></li>
      <li class="list-inline-item"><a href="#">Terms</a></li>
      <li class="list-inline-item"><a href="#">Support</a></li>
    </ul>
  </footer>
</div>

External CSS

  1. https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/4.1.3/css/bootstrap.min.css

External JavaScript

This Pen doesn't use any external JavaScript resources.