[lmkg]

I think this is a great concept that will need a few rounds of feedback and some live testing before it's ready for prime time. Many commenters here are saying the current format will lower conversion rates, and I agree with that, but I think the problems are correctable. I would love to see conversion rates on this thing, although that's sort of a chicken-and-egg problem.

My general attitude: it's trying too hard to look exactly like a credit card, and that makes it not enough like a normal form. Dial it back a notch or two. Have the fillable areas look like normal form fields, don't be afraid to explanatory or error labels on the form, and show front & back at the same time rather than a "flip" interaction.