<!DOCTYPE html>
<html>

<head>
  <meta http-equiv="Content-Type" content="text/html; charset=utf-8">
</head>

<body>
  <form id="testform" method="post">
    <table>
      <tbody>
        <tr>
          <td>
            <label for="name">Name on Card</label>
          </td>
          <td>
            <input size="40" id="name" />
          </td>
        </tr>
        <tr>
          <td>
            <label for="number">Card Number</label>
          </td>
          <td>
            <input size="40" id="number" name="card_number" />
          </td>
        </tr>
        <tr>
          <td>
            <label>Expiration Date</label>
          </td>
          <td>
            <input size="2" id="expiration_month" name="ccmonth"> <input size="4" id="expiration_year"
              name="ccyear" />
          </td>
        </tr>
      </tbody>
    </table>
    <input type="submit" value="Submit">
  </form>
</body>
</html>