<head>
<title>Order Form</title>
</head>
<body topmargin="0" leftmargin="0" >
<h1 align="center" >Order Form </h1><br />
<table align="center" border="0" width="500" cellpadding="0" cellspacing="0">
<tr><td>
<form>
<fieldset style="width:420; height:220;">
<legend align="right">Shipping Address</legend>
<table align="center" bgcolor="pink" border="0" cellpadding="4" cellspacing="0" width="420">
<tr>
<td>Name:</td>
<td><input type="text" size="30" /></td>
</tr>
<tr>
<td valign="top">Street:</td>
<td><textarea rows="3" cols="40" /></textarea></td>
</tr>
<tr>
<td>City:</td>
<td><input type="text" size="30" /></td>
</tr>
<tr>
<td>State:</td>
<td><input type="text" size="20" />
Zip<input type="text" size="10" />
</td>
</tr>
<tr>
<td>Country:</td>
<td><input type="text" size="30" /></td>
</tr>
</table>
</fieldset>
<fieldset style="width:420; height:200;">
<legend align="right">Payment Information</legend>
<table align="center" bgcolor="pink" border="0" cellpadding="4" cellspacing="0" width="420">
<tr>
<td valign="top">Credit Card:</td>
<td> American Express<input type="radio"/><br />
Discover<input type="radio"/><br />
Master Card<input type="radio"/><br />
Visa<input type="radio"/><br />
</td>
</tr>
<tr>
<td>Name on Card:</td>
<td><input type="text" size="30" /></td>
</tr>
<tr>
<td>Card #</td>
<td><input type="text" size="20" /></td>
</tr>
<tr>
<td>Expiration Date:</td>
<td>
<select>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
</select> /
<select>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select> /
<select>
<option>2012</option>
<option>2011</option>
<option>2010</option>
<option>2009</option>
<option>2008</option>
<option>2007</option>
<option>2006</option>
<option>2005</option>
</select> DD/MM/YYYY
</td>
</tr>
</table>
</fieldset>
</form>
<form>
<table align="center">
<tr>
<td>
<input type="Submit" value="Submit Order" />
<input type="Reset" value="Clear Order" />
</td>
</tr>
</table>
</form>
</td></tr>
</table>
</body>
</html>
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