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  1. <form method="post" action="" id="pp_order_form" name="pp_order_form">
  2. <div class="form_wrapper">
  3. 	<p><label for="first_name">First Name:</label><br>
  4. 	<input type="text" name="first_name" id="first_name" value="" style="width: 100px;"/></p>
  5.  
  6. 	<p><label for="last_name">Last Name:</label><br>
  7. 	<input type="text" name="last_name" id="last_name" value="" style="width: 100px;"/></p>
  8.  
  9. 	<p><label for="address">Address:</label><br>
  10. 	<input type="text" name="address" id="address" value="" style="width: 125px;"/></p>
  11.  
  12. 	<p><label for="city">City:</label><br>
  13. 	<input type="text" name="city" id="city" value="" style="width: 100px;"/></p>
  14.  
  15. 	<p><label for="state">State:</label><br>
  16. 	<input type="text" name="state" id="state" value="" style="width: 25px;" maxlength="2" /></p>
  17.  
  18. 	<p><label for="zip">Zip:</label><br>
  19. 	<input type="text" name="zip" id="zip" value="" style="width: 55px;"/></p>
  20.  
  21. 	<p><label for="email">Email Address:</label><br>
  22. 	<input type="text" name="email" id="email" value="" style="width: 125px;" /></p>
  23.  
  24. 	<p align="center"><input type="submit" name="submit_order" id="submit_order" value="Submit Order" /></p>
  25. </div>
  26. </form>

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