chromium/components/test/data/autofill/heuristics/input/105_checkout_m_lowes.com.html

<form id="newCreditCard">
    <fieldset>
      <legend class="hide">New Credit Card</legend>
      
      <select id="ccType" name="paymentMethod" >
        <option value="" selected="selected">Select a card type</option>
        <option value="Lowes Credit Card">Lowe's Consumer Card</option>
        
        <option value="VISA">VISA</option>
        <option value="Master Card">MasterCard</option>
        <option value="AMEX">American Express</option>
        <option value="Discover">Discover</option>
      </select>
      <div id="ccImages"></div>
      <input id="ccNum" name="cardNumber" type="text" placeholder="Credit card number" pattern="[0-9]*" data-maxlength="16">
      
      <div class="securityCode">
        <input type="password" id="sCode" name="sCode" class="securityCode" placeholder="Security Code" pattern="[0-9]*" data-maxlength="4" >
        <a href="#" class="btn btn-tooltip slide-panel" data-element="#ccvModal" data-view="ccvModalTemplate">?</a>
      </div>
      
      <div id="ccExpContainer">
        <fieldset>
          <legend>Expiration Date:</legend>
          <select name="cardExpiryMonth" id="ccExpMonth">
            <option value="" selected="selected">MM</option>
            <option value="01">01</option>
            <option value="02">02</option>
            <option value="03">03</option>
            <option value="04">04</option>
            <option value="05">05</option>
            <option value="06">06</option>
            <option value="07">07</option>
            <option value="08">08</option>
            <option value="09">09</option>
            <option value="10">10</option>
            <option value="11">11</option>
            <option value="12">12</option>
          </select>
          <select name="cardExpiryYear" id="ccExpYear">
            <option value="" selected="selected">YYYY</option>
          <option value="2014">2014</option><option value="2015">2015</option><option value="2016">2016</option><option value="2017">2017</option><option value="2018">2018</option><option value="2019">2019</option><option value="2020">2020</option><option value="2021">2021</option><option value="2022">2022</option></select>
        </fieldset>
      </div>
      
        
      
    </fieldset>
    
    
      
    
  </form>